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Impact of Heart Failure Etiology on Outcomes of Heart Failure with Stable Mid-Range Ejection Fraction
The 23rd Annual Scientific Meeting HFSA respectively. Conclusion: We found that female patients with HFmrEF of 40-49% and stable EF of 1 year had higher all-cause mortality compared to male patients. Further studies are needed to validate our results and identify the responsible factors.
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becoming inotrope dependent and 58% had a “high” likelihood of death, transplant or durable ventricular assist device placement within the next 6 months. Despite these expectations, only 51% of patients had goals of care conversations prior to inotrope initiation. An additional 19% had it after inotrope initiation but before discharge. The average duration of inotrope therapy was 11§12 days. Ultimately, 29% were discharged on inotropes and 26% died or entered hospice by the time of discharge. Provider predictions about the long term need for inotropes or death/hospice was accurate 51% of the time. Conclusions: Over half of patients electively started on inotropes with stable hemodynamics ultimately required home inotropes, died during admission or were discharged to hospice. Heart failure clinicians did not reliably identify those patients with inotropic dependence, death, or hospice by the time of discharge. In light of these poor outcomes and our limited ability to accurately predict them, goals of care discussions should be emphasized prior to inotrope initiation.
424 Impact of Heart Failure Etiology on Outcomes of Heart Failure with Stable MidRange Ejection Fraction Mohamad Khaled Soufi1, Mohamed Faher Almahmoud2, Joseph R. McFarland3, Rishabh R. Jain3, Milin N. Rana3, Simon Pinsky4, Precious Ogbonna3, Wissam I. Khalife1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Department of Cardiology, University of Texas Medical Branch, Galveston, TX; 3University of Texas Medical Branch School of Medicine, Galveston, TX; 4Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX Background: Heart failure with mid-range ejection fraction (HFmrEF) of 40-49% is an under-recognized class of CHF. The impact of heart failure etiology in patients with HFmrEF and stable ejection fraction (EF) of one year is unclear. Objectives: We hypothesized that patients with ischemic cardiomyopathy (ICMP) and stable mid-range EF (mrEF) and patients with non-ischemic cardiomyopathy (NICMP) and stable mrEF have different mortality and morbidity prognosis. Methods: We screened 2593 baseline echo studies at our academic center and identified 724 patients with mrEF. From these patients, we included patients with stable mrEF of 1 year. Student’s T-test and chi-square test were used to assess baseline differences between ICMP and NICMP patients. Kaplan Meier survival analysis was conducted and Logrank p values were calculated to assess the association of different groups with allcause mortality, cardiac mortality, and heart failure (HF) hospitalizations. Multivariate Cox regression analysis was adjusted for age, gender, race, HTN, DM, COPD, and CKD. Results: A total of 132 patients were included in our study. Table 1 summarizes characteristics of patients. Follow up period was 58.7 § 29.1 months. There was no significant difference in all-cause mortality between ICMP and NICMP patients (figure 1), p-value of 0.223. Cardiac mortality between the two groups was not significantly different, p-value of 0.507 and HF hospitalization rate between them was also not significant, p-value of 0.8. In adjusted model, differences in outcomes remained insignificant. Conclusion: We found that patients with ICMP and stable mrEF of 1 year had similar all-cause mortality, cardiac mortality, and HF hospitalization rate compared to patients with NICMP and stable mrEF. Further studies are needed to validate our results.
423 Anticipated vs. Actual Outcomes of Elective Inotrope Initiation in Hemodynamically Stable Heart Failure Patients David Snipelisky1, Marat Fudim2, Antonio Perez3, Matthew Nayor4, Natasha Lever4, David Raymer5, Andrew Rosenbaum6, Omar Abou Ezzeddine6, Lynne W. Stevenson7, Lauren Gilstrap8; 1WellStar Medical Center, Atlanta, GA; 2Duke University Medical Center, Durhum, NC; 3Cleveland Clinic, Cleveland, OH; 4Massachusetts General Hospital, Boston, MA; 5Washington University, St. Louis, MO; 6Mayo Clinic, Rochester, MN; 7Vanderbilt University, Nashville, TN; 8Dartmouth, Lebanon, NH Introduction: The expectations and outcomes of elective inotrope use as adjunctive therapy during heart failure (HF) hospitalization are not known. This prospective study aims to describe the intent and results of inotropic therapy initiated electively during HF hospitalization in hemodynamically stable patients. Methods: We used a prospective, multi-center design in 6 academic medical centers of the Heart Failure Apprentice Network to collect data on hemodynamically stable patients started electively on inotropes. Patients were excluded if deemed to need immediate inotropic therapy for progressive hemodynamic deterioration or other critical care for cardiogenic shock. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed for events through hospital discharge, including documentation of advanced care planning. Baseline data from admission was collected retrospectively. Results: A total of 93 patients were included and average age was 60 years and EF 24%§12%. At the time of inotrope initiation, attending cardiologists thought 50% of patients had a “high or very high” likelihood of
S154 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 cardiac mortality, and HF hospitalization rates. Multivariate Cox regression was adjusted for age, gender, race, HF etiology, HTN, DLP, DM, CAD, NYHA class, and COPD. Results: A total of 205 patients were included in our study. Sixty-six patients (32.1%) had CKD. Table 1 summarizes characteristics of patients. Follow up period was 62.5 § 30.6 months. CKD patients had higher all-cause mortality (figure 1), cardiac mortality, and HF hospitalization rates than NCKD patients, p-value of 0.0001, 0.001, and 0.001 respectively. In adjusted model, all-cause mortality, cardiac mortality, and HF hospitalization rates remained significantly higher in CKD patients (HR = 2.412, 95% CI = 1.34-4.32, p-value = 0.003), (HR = 2.481, 95% CI = 1.12-5.46, p-value = 0.024), and (HR = 1.766, 95% CI = 1.20-2.59, p-value = 0.004) respectively. Conclusion: In patients with HFrEF and stable EF of 1 year, we found that the presence of CKD resulted in significantly higher all-cause mortality, cardiac mortality, and HF hospitalization rates. Further studies are needed to validate our results.
425 Left Ventricular Assist Device Implantation Site Volume and 30 Day Readmissions Aayush Visaria1, Udhay Krishnan2, Samprit Banerjee2, Luke Kim2, Maria Karas2, Irina Sobol2, Evelyn M. Horn2, Parag Goyal2; 1Rutgers New Jersey Medical School, Newark, NJ; 2Weill Cornell Medicine, New York, NY Introduction: Readmissions within 30 days of left ventricular assist device (LVAD) implantation are common, contributing to increased morbidity and cost. The relationship between hospital volume and outcomes after LVAD implantation has not been well established. The purpose of this study was to examine 30-day readmission rates after LVAD implantation, stratified by hospital volume, using the Nationwide Readmissions Database (NRD), an all-payer administrative database. Methods: Using the 2014 NRD, we examined 1,311 adults discharged following LVAD implantation in January-November 2014. We identified LVAD implantations based on ICD-9-CM procedure code 37.66 and excluded patients with concurrent ICD-9-CM codes of heart transplantation (37.51 and 33.60). LVAD site volume was determined by counting the number of LVAD implantations from January through December 2014 at each hospital. We then classified patients into site volume quartiles ( 23, 24-40, 4149, and 50). To determine whether LVAD site volume was independently associated with all-cause 30-day readmission, we conducted multivariable logistic regression accounting for the sample design and adjusting for age, sex, payer status, income quartile, Elixhauser weighted comorbidity index, discharge disposition, pre-LVAD mechanical circulatory support, and length of stay. Results: Among 1,311 patients discharged following LVAD implantation, 363 (27%) were readmitted within 30 days. Patients who experienced an LVAD implantation at a hospital in the lowest quartile of LVAD volume were more likely to have higher comorbidity burden, longer index hospitalization length of stay, and have had their implantation at a smaller hospital (bed size <200) compared to other quartiles. Readmission rates did not differ across site volume quartiles (lowest quartile vs. highest quartile: aOR = 0.84 [0.59, 1.20]). Causes of readmission were similar in the lowest vs. highest quartiles; the most common causes were gastro-intestinal bleeding (22% vs. 21%), arrhythmias (10% vs. 12%), and device complications (11% vs. 11%). Inhospital mortality rates were higher in the lowest quartile compared to the highest quartile, although not statistically significant (lowest: 16%, highest: 12%; p=0.11). Conclusion: LVAD site volume was not associated with 30-day readmission. This suggests that regulatory processes in place to ensure high quality LVAD care across sites in the United States have been effective independent of volume.
426 Impact of Chronic Kidney Disease on Prognosis of Heart Failure with Stable Reduced Ejection Fraction Mohamad Khaled Soufi1, Mohamed Faher Almahmoud2, Joseph R. McFarland3, Rishabh R. Jain3, Simon Pinsky4, Milin N. Rana3, Wissam I. Khalife1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Department of Cardiology, University of Texas Medical Branch, Galveston, TX; 3University of Texas Medical Branch School of Medicine, Galveston, TX; 4Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX Background: Heart failure with reduced ejection fraction (HFrEF) of < 40% is a well-studied class of CHF. Nevertheless, in patients with HFrEF and stable ejection fraction (EF) of 1 year, the impact of CKD on prognosis is unclear. Objectives: We hypothesized that the presence of CKD can result in a worse prognosis in patients with HFrEF and stable EF of 1 year. Methods: At our academic institution, we evaluated 2593 baseline echo studies and their subsequent echo studies to identify HFrEF patients with stable EF of 1 year. Student’s T-test and chi-square test were used to assess baseline differences between CKD and non-chronic kidney disease (NCKD) patients. Kaplan Meier survival analysis was conducted and Log-rank p values were calculated to assess the association of the different groups with all-cause mortality,
427 Patterns of Change in Quality of Life with a Palliative Care Intervention for Patients with Advanced Heart Failure: Insights from PAL-HF Luxi Wan1, Christopher O’Connor1, Amanda Stebbins2, Brooke Alhanti2, Marc D. Samsky1, Haider J. Warraich1,2, Kimberly S. Johnson1,2, Kevin J. Anstrom1,2, Mona Fiuzat1, Bradi B. Granger3, Daniel B. Mark1,2, James A. Tulsky4, Joseph G. Rogers1,2, Robert J. Mentz1,2; 1Duke University School of Medicine, Durham, NC; 2Duke Clinical Research Institute, Durham, NC; 3Duke School of Nursing, Durham, NC; 4Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, MA Background: The PAL-HF trial demonstrated that palliative care improves quality of life (QOL) in advanced heart failure (HF) patients as measured by the Kansas City
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becoming inotrope dependent and 58% had a “high” likelihood of death, transplant or durable ventricular assist device placement within the next 6 months. Despite these expectations, only 51% of patients had goals of care conversations prior to inotrope initiation. An additional 19% had it after inotrope initiation but before discharge. The average duration of inotrope therapy was 11§12 days. Ultimately, 29% were discharged on inotropes and 26% died or entered hospice by the time of discharge. Provider predictions about the long term need for inotropes or death/hospice was accurate 51% of the time. Conclusions: Over half of patients electively started on inotropes with stable hemodynamics ultimately required home inotropes, died during admission or were discharged to hospice. Heart failure clinicians did not reliably identify those patients with inotropic dependence, death, or hospice by the time of discharge. In light of these poor outcomes and our limited ability to accurately predict them, goals of care discussions should be emphasized prior to inotrope initiation.
424 Impact of Heart Failure Etiology on Outcomes of Heart Failure with Stable MidRange Ejection Fraction Mohamad Khaled Soufi1, Mohamed Faher Almahmoud2, Joseph R. McFarland3, Rishabh R. Jain3, Milin N. Rana3, Simon Pinsky4, Precious Ogbonna3, Wissam I. Khalife1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Department of Cardiology, University of Texas Medical Branch, Galveston, TX; 3University of Texas Medical Branch School of Medicine, Galveston, TX; 4Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX Background: Heart failure with mid-range ejection fraction (HFmrEF) of 40-49% is an under-recognized class of CHF. The impact of heart failure etiology in patients with HFmrEF and stable ejection fraction (EF) of one year is unclear. Objectives: We hypothesized that patients with ischemic cardiomyopathy (ICMP) and stable mid-range EF (mrEF) and patients with non-ischemic cardiomyopathy (NICMP) and stable mrEF have different mortality and morbidity prognosis. Methods: We screened 2593 baseline echo studies at our academic center and identified 724 patients with mrEF. From these patients, we included patients with stable mrEF of 1 year. Student’s T-test and chi-square test were used to assess baseline differences between ICMP and NICMP patients. Kaplan Meier survival analysis was conducted and Logrank p values were calculated to assess the association of different groups with allcause mortality, cardiac mortality, and heart failure (HF) hospitalizations. Multivariate Cox regression analysis was adjusted for age, gender, race, HTN, DM, COPD, and CKD. Results: A total of 132 patients were included in our study. Table 1 summarizes characteristics of patients. Follow up period was 58.7 § 29.1 months. There was no significant difference in all-cause mortality between ICMP and NICMP patients (figure 1), p-value of 0.223. Cardiac mortality between the two groups was not significantly different, p-value of 0.507 and HF hospitalization rate between them was also not significant, p-value of 0.8. In adjusted model, differences in outcomes remained insignificant. Conclusion: We found that patients with ICMP and stable mrEF of 1 year had similar all-cause mortality, cardiac mortality, and HF hospitalization rate compared to patients with NICMP and stable mrEF. Further studies are needed to validate our results.
423 Anticipated vs. Actual Outcomes of Elective Inotrope Initiation in Hemodynamically Stable Heart Failure Patients David Snipelisky1, Marat Fudim2, Antonio Perez3, Matthew Nayor4, Natasha Lever4, David Raymer5, Andrew Rosenbaum6, Omar Abou Ezzeddine6, Lynne W. Stevenson7, Lauren Gilstrap8; 1WellStar Medical Center, Atlanta, GA; 2Duke University Medical Center, Durhum, NC; 3Cleveland Clinic, Cleveland, OH; 4Massachusetts General Hospital, Boston, MA; 5Washington University, St. Louis, MO; 6Mayo Clinic, Rochester, MN; 7Vanderbilt University, Nashville, TN; 8Dartmouth, Lebanon, NH Introduction: The expectations and outcomes of elective inotrope use as adjunctive therapy during heart failure (HF) hospitalization are not known. This prospective study aims to describe the intent and results of inotropic therapy initiated electively during HF hospitalization in hemodynamically stable patients. Methods: We used a prospective, multi-center design in 6 academic medical centers of the Heart Failure Apprentice Network to collect data on hemodynamically stable patients started electively on inotropes. Patients were excluded if deemed to need immediate inotropic therapy for progressive hemodynamic deterioration or other critical care for cardiogenic shock. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed for events through hospital discharge, including documentation of advanced care planning. Baseline data from admission was collected retrospectively. Results: A total of 93 patients were included and average age was 60 years and EF 24%§12%. At the time of inotrope initiation, attending cardiologists thought 50% of patients had a “high or very high” likelihood of
S154 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 cardiac mortality, and HF hospitalization rates. Multivariate Cox regression was adjusted for age, gender, race, HF etiology, HTN, DLP, DM, CAD, NYHA class, and COPD. Results: A total of 205 patients were included in our study. Sixty-six patients (32.1%) had CKD. Table 1 summarizes characteristics of patients. Follow up period was 62.5 § 30.6 months. CKD patients had higher all-cause mortality (figure 1), cardiac mortality, and HF hospitalization rates than NCKD patients, p-value of 0.0001, 0.001, and 0.001 respectively. In adjusted model, all-cause mortality, cardiac mortality, and HF hospitalization rates remained significantly higher in CKD patients (HR = 2.412, 95% CI = 1.34-4.32, p-value = 0.003), (HR = 2.481, 95% CI = 1.12-5.46, p-value = 0.024), and (HR = 1.766, 95% CI = 1.20-2.59, p-value = 0.004) respectively. Conclusion: In patients with HFrEF and stable EF of 1 year, we found that the presence of CKD resulted in significantly higher all-cause mortality, cardiac mortality, and HF hospitalization rates. Further studies are needed to validate our results.
425 Left Ventricular Assist Device Implantation Site Volume and 30 Day Readmissions Aayush Visaria1, Udhay Krishnan2, Samprit Banerjee2, Luke Kim2, Maria Karas2, Irina Sobol2, Evelyn M. Horn2, Parag Goyal2; 1Rutgers New Jersey Medical School, Newark, NJ; 2Weill Cornell Medicine, New York, NY Introduction: Readmissions within 30 days of left ventricular assist device (LVAD) implantation are common, contributing to increased morbidity and cost. The relationship between hospital volume and outcomes after LVAD implantation has not been well established. The purpose of this study was to examine 30-day readmission rates after LVAD implantation, stratified by hospital volume, using the Nationwide Readmissions Database (NRD), an all-payer administrative database. Methods: Using the 2014 NRD, we examined 1,311 adults discharged following LVAD implantation in January-November 2014. We identified LVAD implantations based on ICD-9-CM procedure code 37.66 and excluded patients with concurrent ICD-9-CM codes of heart transplantation (37.51 and 33.60). LVAD site volume was determined by counting the number of LVAD implantations from January through December 2014 at each hospital. We then classified patients into site volume quartiles ( 23, 24-40, 4149, and 50). To determine whether LVAD site volume was independently associated with all-cause 30-day readmission, we conducted multivariable logistic regression accounting for the sample design and adjusting for age, sex, payer status, income quartile, Elixhauser weighted comorbidity index, discharge disposition, pre-LVAD mechanical circulatory support, and length of stay. Results: Among 1,311 patients discharged following LVAD implantation, 363 (27%) were readmitted within 30 days. Patients who experienced an LVAD implantation at a hospital in the lowest quartile of LVAD volume were more likely to have higher comorbidity burden, longer index hospitalization length of stay, and have had their implantation at a smaller hospital (bed size <200) compared to other quartiles. Readmission rates did not differ across site volume quartiles (lowest quartile vs. highest quartile: aOR = 0.84 [0.59, 1.20]). Causes of readmission were similar in the lowest vs. highest quartiles; the most common causes were gastro-intestinal bleeding (22% vs. 21%), arrhythmias (10% vs. 12%), and device complications (11% vs. 11%). Inhospital mortality rates were higher in the lowest quartile compared to the highest quartile, although not statistically significant (lowest: 16%, highest: 12%; p=0.11). Conclusion: LVAD site volume was not associated with 30-day readmission. This suggests that regulatory processes in place to ensure high quality LVAD care across sites in the United States have been effective independent of volume.
426 Impact of Chronic Kidney Disease on Prognosis of Heart Failure with Stable Reduced Ejection Fraction Mohamad Khaled Soufi1, Mohamed Faher Almahmoud2, Joseph R. McFarland3, Rishabh R. Jain3, Simon Pinsky4, Milin N. Rana3, Wissam I. Khalife1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Department of Cardiology, University of Texas Medical Branch, Galveston, TX; 3University of Texas Medical Branch School of Medicine, Galveston, TX; 4Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX Background: Heart failure with reduced ejection fraction (HFrEF) of < 40% is a well-studied class of CHF. Nevertheless, in patients with HFrEF and stable ejection fraction (EF) of 1 year, the impact of CKD on prognosis is unclear. Objectives: We hypothesized that the presence of CKD can result in a worse prognosis in patients with HFrEF and stable EF of 1 year. Methods: At our academic institution, we evaluated 2593 baseline echo studies and their subsequent echo studies to identify HFrEF patients with stable EF of 1 year. Student’s T-test and chi-square test were used to assess baseline differences between CKD and non-chronic kidney disease (NCKD) patients. Kaplan Meier survival analysis was conducted and Log-rank p values were calculated to assess the association of the different groups with all-cause mortality,
427 Patterns of Change in Quality of Life with a Palliative Care Intervention for Patients with Advanced Heart Failure: Insights from PAL-HF Luxi Wan1, Christopher O’Connor1, Amanda Stebbins2, Brooke Alhanti2, Marc D. Samsky1, Haider J. Warraich1,2, Kimberly S. Johnson1,2, Kevin J. Anstrom1,2, Mona Fiuzat1, Bradi B. Granger3, Daniel B. Mark1,2, James A. Tulsky4, Joseph G. Rogers1,2, Robert J. Mentz1,2; 1Duke University School of Medicine, Durham, NC; 2Duke Clinical Research Institute, Durham, NC; 3Duke School of Nursing, Durham, NC; 4Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, MA Background: The PAL-HF trial demonstrated that palliative care improves quality of life (QOL) in advanced heart failure (HF) patients as measured by the Kansas City