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Immediate vs delayed diagnosis of heart failure: is there a difference in outcomes? results of a harris interactive® Patient Survey
The 8th Annual Scientific Meeting
•
HFSA
S125
400
402
Immediate vs Delayed Diagnosis of Heart Failure: Is There a Difference in Outcomes? Results of a Harris Interactive쏐 Patient Survey Brenda S. Thompson,1 Clyde W. Yancy1; 1Internal Medicine/Cardiology, UT Southwestern Medical Center, Dallas, TX
Effective Beta-Blockade Impacts the Course of Heart Failure in Patients with Diabetic Cardiomyopathy Ambika Bhaskaran,1 Robert M. Siegel,2 Barbara Barker,1 Jennifer Vermillion,1 Steven King,1 James Romo1; 1Division of Cardiovascular Research, Advanced Cardiac Specialists, Gilbert, AZ; 2Department of Cardiology, Mesa General Hospital, Mesa, AZ
Background: Heart failure remains a compelling problem with morbidity rates as high as 50% within 5 years of diagnosis and a hospitalization burden of over 1 million episodes per year. Problem: It is unclear if the time delay between the onset of symptoms and the initiation of medical therapy for heart failure [HF] contributes to excess morbidity from HF. Method: Patients were identified through a Chronic Illness Panel managed by Harris Interactive쑓. We evaluated a cohort of 261 patients, invited by email solicitation to participate in a self-administered online survey. The patient sample was adjusted to approximate the U.S. adult CHF population. Statistical significance was determined at a p value ⬍0.05 with a confidence limit of 95%. Demographics: Gender M:F- 59%/41%; Race W/other- 92%/8%; NYHA Class I/II/III/IV - 31%/29%/32%/8%. Results: With the onset of symptoms 45% of the patients received an immediate diagnosis of HF and 43% experienced a delayed diagnosis. 33% of the overall population was diagnosed in a hospital emergency room and 21% after hospital admission. Thus greater than 50% of cases were diagnosed as an acute event. 12% were uncertain regarding the onset of symptoms. Delayed diagnosis resulted from patients not seeking treatment at the onset of symptoms or being misdiagnosed. Of those surveyed with a delayed diagnosis 18% were diagnosed in ⬍ a year, 15% in 1–5 years, 10% ⬎5 years after the onset of symptoms. The mean number of prescription medications taken by patients with a delayed diagnosis vs. immediate diagnosis was 3.6 vs. 2.9 [p ⬍ 0.05]. Patients with a delayed diagnosis had more shortness of breath, fatigue, palpitations and cough [p ⬍ 0.05]. See Table for additional between group characteristics. Conclusions: We conclude that patients with a delayed diagnosis have more morbidity than those with an immediate diagnosis. Patients with a delayed diagnosis suffer more symptoms, take more medications, and tend to utilize more hospital resources and are likely to suffer from other comorbidities such as diabetes and depression that may affect their symptom presentation or health care seeking behavior. Over 50% of patients are diagnosed during an acute event which represents the best moment for patient education, thus yielding an opportunity to improve heart failure related morbidity, as well as reducing the number of healthcare resources consumed by a delayed diagnosis of heart failure. Dealyed vs. Immediate Diagnosis of HF # of symptoms 12 mo.Hosp 12 mo. ED visits Diabetes Depression
4.7 2.1 2.3 56% 36%
3.6 1.2 1.4 47% 27%
p ⫽ NS
401 Dietitian Intervention for Patients with Heart Failure Results in Improved Compliance with a Sodium Restricted Diet: A Randomized Trial JoAnne Arcand,1 Sandra Brazel,1 Courtney Joliffe,1 Marlene Choleva,1 Frances Berkoff,1 Johane P. Allard,2 Gary E. Newton1; 1Department of Medicine, Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada; 2Department of Medicine, Division of Gastroenterology, University Health Newtork, Toronto, ON, Canada Background: Multidisciplinary heart failure programs are successful in reducing hospital readmission and improving outcomes. Although dietitians are often members of the team, no randomized studies have demonstrated the benefit of dietitians independent of the multidisciplinary team. Therefore, the purpose of this study was to evaluate the effect of dietitian intervention for a sodium restricted diet in ambulatory patients with stable heart failure. Methods: We conducted a randomized controlled trial. Patients were randomized into a dietitian intervention group or a usual care group and were followed for three months. Both groups received a 2g dietary sodium prescription. The control group received nutrition advice by way of self-help literature, while the intervention group returned for two counseling sessions with a dietitian. Results: Forty eight patients were included in the final analysis. Dietitian intervention resulted in a significant decrease in dietary sodium intake at three months from 2799 ⫾ 297mg/day to 2142 ⫾ 231mg/day (p ⬍ 0.05). In contrast, there was no change in dietary sodium intake in the usual care group. Conclusions: Dietitian counseling, in contrast to simply providing literature, was more effective in reducing dietary sodium intake in patients with stable heart failure.
Diabetes is recognized as an independent risk factor for the development of heart failure (HF). The spectrum of diabetic cardiomyopathy (CMP) encompasses a multifactorial etiology characterized by structural and functional alterations to the myocardium and coronary vasculature. Of concern, the use of beta-blockers (BB) in this population continues to be low. Limited data is available regarding the effectiveness of BB on clinical outcomes in diabetics with LV dysfunction and HF. We examined our HF registry data with the aim of evaluating baseline characteristics and 1-year clinical outcomes in diabetic patients who receive BB. Of the 402 patients who presented to the HF Clinic between 1/2000 and 11/2003, 122 (30.3%) were diabetic; 78 of them (64%) were initiated on BB at presentation. Mean age was 66.9 years; 76% male. Primary etiology of CHF was ischemic in 82% and hypertension in 9%. Functional, clinical and therapeutic variables were compared at baseline and at 1 year after referral. Results Variable NYHA I (%)
NYHA III-IV (%) Mean NYHA Systolic B.P. (mmHg) Diastolic Dysfunction (%) Mean LVEF (%) LVID(d) (mm) LA size (mm) PAP (systolic) (mmHg) Atrial Fibrillation (%) ACE-Inhibitor (%) Diuretics (%) IV Inotrope (%) BUN (mg/dL) Creatinine (mg/dL)
Baseline
12-month F/U
10.1
35.9
57.7 2.8 129.79 46.2 29.9 59.5 45 46 10.3 74.4 82 5.2 28.07 1.27
14.1 2.0 123.15 17.0 36.7 57 47 34 1.3 71.6 37.2 2.6 30.01 1.32
‘P’ value 0.031*
0.031* ⬍0.0001* 0.043* 0.023* 0.019* 0.000* 0.476 0.000* 0.045* 0.345 0.000* 0.000* 0.875 0.224
*P value significant at ⱕ0.05 At 1-year follow-up, 12.1% had made at least one visit to the ER and 10.2% had been hospitalized for worsening CHF. Cardiac mortality was 5.1%. Conclusions: In diabetic patients with CMP and HF, addition of BB to therapy was associated with significant improvement in multiple hemodynamic parameters, arrhythmias, LV dimensions and systolic and diastolic performance at the end of 1 year. This translated into significant improvement in functional class and lower rates of hospitalization and mortality, compared to published data in diabetics. Our experience demonstrates that effective beta-blockade may be an important factor in improving signs and symptoms and producing clinically meaningful reductions in mortality and morbidity in diabetics presenting with CMP and HF.
403 Use of Vasodilators in the Emergency Department Treatment of Acute Decompensated Heart Failure Patients Deborah B. Diercks,1 J. Douglas Kirk,1 W. Franklin Peacock,2 Jim Edward Weber3; 1 Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA; 2Emergency Medicine, Cleveland Clinic Foundation, Cleveland, OH; 3Emergency Medicine, University of Michigan, Ann Arbor, MI Background: Vasodilators are valuable in the treatment of acutely decompensated heart failure (adHF) although they are not consistently utilized in the emergency department (ED). Objective: To describe factors affecting ED vasodilator utilization and it’s association with outcome. Methods: A retrospective analysis of a sample abstracted from all adHF patients presenting to a tertiary care medical center ED during 2004. Eligible patients had a final ED or inpatient diagnosis of adHF based on billing codes. Vasodilator usage was defined as receiving any nitroglycerin, or nesiritide, alone or in combination. Patient demographics were obtained from selfreport or chart review. Electrocardiograms were interpreted by the treating physician for the presence or absence of an ischemic/infarction pattern (iECG). Adverse events were defined as death, recurrent myocardial infarction, or repeat hospitalization within 30 days. Univariate analysis was performed on the following variables to determine if there was an association with vasodilator usage: gender, age ⬎ 70, past medical history of diabetes, hypertension, congestive heart failure, renal insufficiency, coronary artery disease, systolic blood pressure ⬎ 160 mmHg, iECG, creatinine ⬎ 2.5 mg/dl, BUN ⬎ 60 mg/dl, normal initial troponin I level, and a radiologist’s reading of pulmonary edema on chest radiography. Significant variables (p ⬍ 0.05) were entered into a multivariate analysis. Results: There were 288 patients, with a mean age of 60.9 years (SD 14). Women comprised 48% (n ⫽ 148) of the sample. Vasodilators were used in 153 (53%). Overall, there were 37(13%) adverse events, and 59 patients (21%) were discharged home. There was no difference in the use of vasodilators and adverse events (OR 1.7, 95% CI 0.6–2.5). The significant variables in the univariate analysis were creatinine, systolic blood pressure, iECG, and history of renal insufficiency. These were then entered into multivariate analysis. Only an iECG was an independent predictor of vasodilator use (OR 5.9, 95% CI 1.69–20.9). Conclusion: Only the presence of iECG identified patients more likely to receive vasodilators. However vasodilator use in the ED was not associated with an appreciable difference in adverse events. Larger studies may be warranted to determine vasodilator utilization affects outcomes.
•
HFSA
S125
400
402
Immediate vs Delayed Diagnosis of Heart Failure: Is There a Difference in Outcomes? Results of a Harris Interactive쏐 Patient Survey Brenda S. Thompson,1 Clyde W. Yancy1; 1Internal Medicine/Cardiology, UT Southwestern Medical Center, Dallas, TX
Effective Beta-Blockade Impacts the Course of Heart Failure in Patients with Diabetic Cardiomyopathy Ambika Bhaskaran,1 Robert M. Siegel,2 Barbara Barker,1 Jennifer Vermillion,1 Steven King,1 James Romo1; 1Division of Cardiovascular Research, Advanced Cardiac Specialists, Gilbert, AZ; 2Department of Cardiology, Mesa General Hospital, Mesa, AZ
Background: Heart failure remains a compelling problem with morbidity rates as high as 50% within 5 years of diagnosis and a hospitalization burden of over 1 million episodes per year. Problem: It is unclear if the time delay between the onset of symptoms and the initiation of medical therapy for heart failure [HF] contributes to excess morbidity from HF. Method: Patients were identified through a Chronic Illness Panel managed by Harris Interactive쑓. We evaluated a cohort of 261 patients, invited by email solicitation to participate in a self-administered online survey. The patient sample was adjusted to approximate the U.S. adult CHF population. Statistical significance was determined at a p value ⬍0.05 with a confidence limit of 95%. Demographics: Gender M:F- 59%/41%; Race W/other- 92%/8%; NYHA Class I/II/III/IV - 31%/29%/32%/8%. Results: With the onset of symptoms 45% of the patients received an immediate diagnosis of HF and 43% experienced a delayed diagnosis. 33% of the overall population was diagnosed in a hospital emergency room and 21% after hospital admission. Thus greater than 50% of cases were diagnosed as an acute event. 12% were uncertain regarding the onset of symptoms. Delayed diagnosis resulted from patients not seeking treatment at the onset of symptoms or being misdiagnosed. Of those surveyed with a delayed diagnosis 18% were diagnosed in ⬍ a year, 15% in 1–5 years, 10% ⬎5 years after the onset of symptoms. The mean number of prescription medications taken by patients with a delayed diagnosis vs. immediate diagnosis was 3.6 vs. 2.9 [p ⬍ 0.05]. Patients with a delayed diagnosis had more shortness of breath, fatigue, palpitations and cough [p ⬍ 0.05]. See Table for additional between group characteristics. Conclusions: We conclude that patients with a delayed diagnosis have more morbidity than those with an immediate diagnosis. Patients with a delayed diagnosis suffer more symptoms, take more medications, and tend to utilize more hospital resources and are likely to suffer from other comorbidities such as diabetes and depression that may affect their symptom presentation or health care seeking behavior. Over 50% of patients are diagnosed during an acute event which represents the best moment for patient education, thus yielding an opportunity to improve heart failure related morbidity, as well as reducing the number of healthcare resources consumed by a delayed diagnosis of heart failure. Dealyed vs. Immediate Diagnosis of HF # of symptoms 12 mo.Hosp 12 mo. ED visits Diabetes Depression
4.7 2.1 2.3 56% 36%
3.6 1.2 1.4 47% 27%
p ⫽ NS
401 Dietitian Intervention for Patients with Heart Failure Results in Improved Compliance with a Sodium Restricted Diet: A Randomized Trial JoAnne Arcand,1 Sandra Brazel,1 Courtney Joliffe,1 Marlene Choleva,1 Frances Berkoff,1 Johane P. Allard,2 Gary E. Newton1; 1Department of Medicine, Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada; 2Department of Medicine, Division of Gastroenterology, University Health Newtork, Toronto, ON, Canada Background: Multidisciplinary heart failure programs are successful in reducing hospital readmission and improving outcomes. Although dietitians are often members of the team, no randomized studies have demonstrated the benefit of dietitians independent of the multidisciplinary team. Therefore, the purpose of this study was to evaluate the effect of dietitian intervention for a sodium restricted diet in ambulatory patients with stable heart failure. Methods: We conducted a randomized controlled trial. Patients were randomized into a dietitian intervention group or a usual care group and were followed for three months. Both groups received a 2g dietary sodium prescription. The control group received nutrition advice by way of self-help literature, while the intervention group returned for two counseling sessions with a dietitian. Results: Forty eight patients were included in the final analysis. Dietitian intervention resulted in a significant decrease in dietary sodium intake at three months from 2799 ⫾ 297mg/day to 2142 ⫾ 231mg/day (p ⬍ 0.05). In contrast, there was no change in dietary sodium intake in the usual care group. Conclusions: Dietitian counseling, in contrast to simply providing literature, was more effective in reducing dietary sodium intake in patients with stable heart failure.
Diabetes is recognized as an independent risk factor for the development of heart failure (HF). The spectrum of diabetic cardiomyopathy (CMP) encompasses a multifactorial etiology characterized by structural and functional alterations to the myocardium and coronary vasculature. Of concern, the use of beta-blockers (BB) in this population continues to be low. Limited data is available regarding the effectiveness of BB on clinical outcomes in diabetics with LV dysfunction and HF. We examined our HF registry data with the aim of evaluating baseline characteristics and 1-year clinical outcomes in diabetic patients who receive BB. Of the 402 patients who presented to the HF Clinic between 1/2000 and 11/2003, 122 (30.3%) were diabetic; 78 of them (64%) were initiated on BB at presentation. Mean age was 66.9 years; 76% male. Primary etiology of CHF was ischemic in 82% and hypertension in 9%. Functional, clinical and therapeutic variables were compared at baseline and at 1 year after referral. Results Variable NYHA I (%)
NYHA III-IV (%) Mean NYHA Systolic B.P. (mmHg) Diastolic Dysfunction (%) Mean LVEF (%) LVID(d) (mm) LA size (mm) PAP (systolic) (mmHg) Atrial Fibrillation (%) ACE-Inhibitor (%) Diuretics (%) IV Inotrope (%) BUN (mg/dL) Creatinine (mg/dL)
Baseline
12-month F/U
10.1
35.9
57.7 2.8 129.79 46.2 29.9 59.5 45 46 10.3 74.4 82 5.2 28.07 1.27
14.1 2.0 123.15 17.0 36.7 57 47 34 1.3 71.6 37.2 2.6 30.01 1.32
‘P’ value 0.031*
0.031* ⬍0.0001* 0.043* 0.023* 0.019* 0.000* 0.476 0.000* 0.045* 0.345 0.000* 0.000* 0.875 0.224
*P value significant at ⱕ0.05 At 1-year follow-up, 12.1% had made at least one visit to the ER and 10.2% had been hospitalized for worsening CHF. Cardiac mortality was 5.1%. Conclusions: In diabetic patients with CMP and HF, addition of BB to therapy was associated with significant improvement in multiple hemodynamic parameters, arrhythmias, LV dimensions and systolic and diastolic performance at the end of 1 year. This translated into significant improvement in functional class and lower rates of hospitalization and mortality, compared to published data in diabetics. Our experience demonstrates that effective beta-blockade may be an important factor in improving signs and symptoms and producing clinically meaningful reductions in mortality and morbidity in diabetics presenting with CMP and HF.
403 Use of Vasodilators in the Emergency Department Treatment of Acute Decompensated Heart Failure Patients Deborah B. Diercks,1 J. Douglas Kirk,1 W. Franklin Peacock,2 Jim Edward Weber3; 1 Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA; 2Emergency Medicine, Cleveland Clinic Foundation, Cleveland, OH; 3Emergency Medicine, University of Michigan, Ann Arbor, MI Background: Vasodilators are valuable in the treatment of acutely decompensated heart failure (adHF) although they are not consistently utilized in the emergency department (ED). Objective: To describe factors affecting ED vasodilator utilization and it’s association with outcome. Methods: A retrospective analysis of a sample abstracted from all adHF patients presenting to a tertiary care medical center ED during 2004. Eligible patients had a final ED or inpatient diagnosis of adHF based on billing codes. Vasodilator usage was defined as receiving any nitroglycerin, or nesiritide, alone or in combination. Patient demographics were obtained from selfreport or chart review. Electrocardiograms were interpreted by the treating physician for the presence or absence of an ischemic/infarction pattern (iECG). Adverse events were defined as death, recurrent myocardial infarction, or repeat hospitalization within 30 days. Univariate analysis was performed on the following variables to determine if there was an association with vasodilator usage: gender, age ⬎ 70, past medical history of diabetes, hypertension, congestive heart failure, renal insufficiency, coronary artery disease, systolic blood pressure ⬎ 160 mmHg, iECG, creatinine ⬎ 2.5 mg/dl, BUN ⬎ 60 mg/dl, normal initial troponin I level, and a radiologist’s reading of pulmonary edema on chest radiography. Significant variables (p ⬍ 0.05) were entered into a multivariate analysis. Results: There were 288 patients, with a mean age of 60.9 years (SD 14). Women comprised 48% (n ⫽ 148) of the sample. Vasodilators were used in 153 (53%). Overall, there were 37(13%) adverse events, and 59 patients (21%) were discharged home. There was no difference in the use of vasodilators and adverse events (OR 1.7, 95% CI 0.6–2.5). The significant variables in the univariate analysis were creatinine, systolic blood pressure, iECG, and history of renal insufficiency. These were then entered into multivariate analysis. Only an iECG was an independent predictor of vasodilator use (OR 5.9, 95% CI 1.69–20.9). Conclusion: Only the presence of iECG identified patients more likely to receive vasodilators. However vasodilator use in the ED was not associated with an appreciable difference in adverse events. Larger studies may be warranted to determine vasodilator utilization affects outcomes.