- Email: [email protected]
Outpatient Ultrafiltration as an Alternative to Hospitalization for Mild to Moderate Decompensated Heart Failure
The 17th Annual Scientific Meeting for cancer-therapy-associated cardiac abnormalities from 2008-present. A comprehensive review of patient records was performed, with documentation of baseline characteristics, cardiac imaging, cardiac medications, and clinical course. Results: 79 consecutive patients who had drops in their LVEF associated with cancer therapy were included. The most common malignancies were breast (46%) and hematologic (35%); 71% of patients were female, and the mean age was 52 +/- 13 years. The primary cancer therapeutics associated with LVEF drop included anthracyclines, trastuzumab, and tyrosine kinase inhibitors. The mean LVEF prior to cancer therapy was 60%, and post-cancer therapy was 40%. The most common cardiac interventions included beta-blockers (84%), ACE-inhibitors/angiotensin receptor blockers (83%); mean LVEF after cardiac intervention was 53%. 77% of the patients had LVEF recovery to $50%, and 68% of these patients had recovery within 6 months of starting cardiac therapy. 76% of patients were able to continue their planned cancer therapy. Conclusions: With appropriate cardiac intervention, the majority of patients with LVEF decline from cancer therapy can achieve LVEF recovery and complete their chemotherapy.
HFSA
S87
level, 68% frail (Fried frailty criteria), 23% with high probability of cognitive impairment (Mini-Cog). Ninety-one percent of subjects were confident in managing medications, though only 11% were able to complete MMAT without errors (Figure). Specifically, 93% were able to read pill bottle labels, 89% were able to open pill bottles, 18% could correctly allocate mock medications into pillbox, and 72% were able to locate correct slot. Of pill allocation failures, 48% failed based on comprehension, 28% failed based on logic, 17% failed due to clerical errors, and 7% refused to complete test. Conclusions: Self-perception and observed ability to manage medications are discordant in older adults hospitalized for HF. This may represent a root cause for downstream medication non-adherence. We describe a novel MMAT that has construct validity in adults hospitalized for HF and may be used in future investigations.
252 Participation in a Multi-Disciplinary Heart Failure Disease Management Program (HFDMP) Minimizes Risk of Aldosterone Antagonist-Induced Hyperkalemia Kristyn Mulqueen, Shawn Anderson, Tamarah Jungklaus, Samantha Malloy, Timothy Cleeton, Jesus Acosta, Jennifer Darago, Richard Schofield; North Florida/ South Georgia Veterans Health System, Gainesville, FL Introduction: Aldosterone antagonists (AA) have been shown to reduce mortality and morbidity in a number of large, randomized controlled trials. Clinical practice guidelines recommend AA therapy for patients with heart failure with reduced ejection fraction (HFrEF), even in those with mild symptoms; however, these agents are often underutilized. Although clinical trials showed relatively low rates of significant hyperkalemia with AA therapy, some observational studies suggest that hyperkalemia occurs more frequently in clinical practice. As a result, some providers may hesitate to prescribe AAs. Hypothesis: Evidence-based prescribing of AAs with appropriate monitoring results in rates of hyperkalemia similar to those seen with standard heart failure (HF) therapy without an AA. Methods: A retrospective review of HF patients followed in a multi-disciplinary Heart Failure Disease Management Program (HFDMP) was performed to compare the incidence of hyperkalemia in patients managed with HF pharmacotherapy with AA (AA therapy group) or without AA (standard therapy group). Inpatient and outpatient medical records were reviewed to identify episodes of hyperkalemia occurring while patients were enrolled in the HFDMP. Hyperkalemia was classified as clinical (K $ 6 mmol/L) or subclinical (6 mmol/L O K $ 5.5 mmol/L). Hyperkalemic events were excluded if the blood sample was hemolyzed. One hundred fifty patients were needed in each group to have 80% power to detect a difference in the rate of hyperkalemia, using expected rates of 15% in the AA therapy group and 2% in the standard therapy group. Results: A total of 300 patients were included in the study. Clinical hyperkalemia occurred in 5 (3.3%) patients in the AA therapy group and 6 (4%) patients in the standard therapy group (p50.76). Subclinical hyperkalemia occurred in 15 (10%) patients in the AA therapy group and 22 (15%) patients in the standard therapy group (p50.22). The observed rate of any hyperkalemia for patients on AA therapy and standard therapy was 13.3% and 18.7%, respectively (p50.21). Conclusions: We found no statistically significant difference in the rate of hyperkalemia between groups of HFDMP patients treated with AA compared with those receiving standard HF therapy. Appropriate patient selection, close laboratory monitoring and follow-up allow for the safe use of AA therapy in patients with HFrEF.
253 Patients Hospitalized for Heart Failure Have Difficulties Managing Medications Despite Reported Self-Confidence Erik H. Howell1, Alpana Senapati1, Eiran Z. Gorodeski2; 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH Introduction: Medication non-adherence is prevalent and associated with poor outcomes. Root causes are not clearly understood. The ability of patients to manage their own medications is not routinely assessed at time of hospital discharge. We developed a novel medication management assessment tool (MMAT) and applied it to patients hospitalized for HF. Hypothesis: Patients hospitalized for HF have under recognized poor medication self-management skills. Methods: We prospectively enrolled inpatients transitioning from hospital-to-home after hospitalization for HF. Prior to discharge, MMAT was deployed under direct observation. MMAT involved a series of tasks focused on allocating mock medications into a weekly pillbox. Prior to testing subjects were asked “Do you feel confident managing your medications on a daily basis?” Subjects were then provided 5 pill bottles representing common HF medications, each filled with 30 mock pills. Four components were assessed pass/ fail: (1) ability to read pill bottle label, verbally stating medication name and instructions; (2) ability to open pill bottle; (3) ability to allocate pills into pillbox correctly; (4) ability to locate specific slot in pillbox. Failure to allocate pills correctly was further subdivided into four categories: (1) Failure in comprehension (no discernible method of allocating pills); (2) Failure in logic (method of allocating pills has repeated error); (3) Clerical errors (appropriate comprehension and logic but !25% of pills allocated incorrectly) and (4) Refusal to complete MMAT after initiation. Results: Of 94 subjects approached 56 consented. Mean age was 77 [range 66-92], 73% male, 64% Caucasian, 32% with HFPEF (LVEF$50%), 30% with low health literacy
254 Outpatient Ultrafiltration as an Alternative to Hospitalization for Mild to Moderate Decompensated Heart Failure Sitaramesh Emani1, Jennifer Host1, Tara L. Baxter1, Todd Yamokoski1, Matthew R. Potter2, Kyle Porter3, Garrie Haas1; 1The Ohio State University, Columbus, OH; 2The Ohio State University, Columbus, OH; 3The Ohio State University, Columbus, OH Background: We previously reported data suggesting feasibility and safety of an outpatient ultrafiltration (UF) protocol to treat mild-moderate acute decompensated heart failure (ADHF). In follow up, we tracked 30-day outcomes following outpatient UF with the hypothesis that outcomes would mirror those of ADHF hospitalizations. Furthermore, we propose that outpatient UF may be a cost-effective alternative to hospitalization in this highly selected population. Methods: We retrospectively analyzed the medical record of consecutive patients who underwent outpatient UF per our established protocol. Treatment characteristics and efficacy were recorded. Unplanned hospitalizations or emergency room visits were tracked for 30 days. Finally, the cost of each outpatient UF treatment was compared to the average cost of an ADHF admission. Results: A total of 37 treatment episodes were identified. Each episode met criteria of outpatient UF based on our previously presented criteria. Demographic data are shown in table 1. Weight decreased by 7.1 kg (95% CI 5.4, 8.8) and creatinine changed by 0.01 (CI -0.10, 0.11). The rate of unplanned admission or ER visits at 30 days postUF was 24% (CI 10, 44%), which is comparable to a national ADHF readmission rate of 27%. The average charge for outpatient UF was $25,500 per treatment ($11,100/ day), which is less than typical inpatient charges for an ADHF hospitalization at our institution (based on a national average length of stay of 6.4 days). Reimbursement for outpatient at present is highly variable based on payer source. Conclusions: Outpatient UF can serve as an alternative to inpatient admission for selected cases of Demographic Data Average Age
59.6 yrs
Male ICM HFpEF Daily furosemide equivalent Thiazide use Number of UF days/episode
78% 65% 11% 161.1 mg 38% 2.3
S88 Journal of Cardiac Failure Vol. 19 No. 8S August 2013 mild-moderate ADHF. Intermediate outcomes are similar to reported rates for hospitalization, but outpatient UF may represent a cost effective way to provide therapy.
255 Impact of Digoxin Loading on Hemodynamics in Advanced Low Output Heart Failure: A Case-Series Review Rajakrishnan Vijayakrishnan1, W.H. Wilson Tang2, Maria Mountis2, David Taylor2, Randall Starling2, Mazen Hanna2; 1Geisinger Medical Center, Danville, PA; 2 Cleveland Clinic Foundation, Cleveland, OH Introduction: Cardiac glycosides are the only available oral agents which have positive inotropic effects and do not increase myocardial oxygen consumption. We conducted a single center study of acute intravenous digoxin loading in patients with low output decompensated heart failure (HF) with hemodynamic monitoring. Hypothesis: Digoxin loading is safe and effective in improving cardiac index (CI) and decreasing the need for IV inotropic support in low output decompensated HF. Methods: A total of 10 patients with low output HF monitored with a Swan Ganz catheter were loaded with 1 mg of Digoxin over a 24 hour period. Loading dose was given intravenously as 0.5 mg followed by 0.25 mg in six hours and then 0.25 mg six hours later. Hemodynamic variables were obtained before and after digoxin loading. Safety end points included atrial and ventricular arrhythmias and digoxin level at 72 hours after loading. Results: Baseline echocardiographic and hemodynamic variables were consistent with advanced HF, with a mean LVEF of 15 +/- 5 %, a baseline mean CI of 1.67 L/min/m2 and a mean PCWP of 27.4 mm Hg. After Digoxin loading, CI improved by a mean of 60.1 % (0% to 135.7%) and PCWP decreased by 38.2% (11% to 50%). Mean arterial pressure remained stable along with mean heart rate change of -2.1 % (-20. 6 % to +11.4%). Four patients who were IV inotrope dependent were successfully transitioned off IV inotropes to oral agents. None of the patients had any significant atrial or ventricular arrhythmias during the ICU stay. Digoxin levels were consistently below 2 ng/ml at 72 hours post digoxin loading. Conclusions: We demonstrated the efficacy and safety of IV digoxin loading in acutely improving cardiac index and facilitating weaning off IV inotropes in the setting of low output decompensated HF.
256 The Intersection of Knowledge Transfer and Health Literacy in Reducing Readmission Rates for Heart Failure John D. Filippone1, Madeline Cafiero2, Kathleen A. Kelly2, Cathleen M. Daley1; 1St Peter’s Health Partners, Albany, NY; 2The Sage Colleges, Troy, NY Introduction: Heart failure is a complex chronic disease requiring an acceptable level of health literacy to better integrate knowledge and skills related to self-efficacy and disease management. The aim of this study is to show that testing for health literacy through a nurse-led inpatient educational program will enhance patients’ understanding of chronic illness and better enable them to understand lifestyle changes necessary for improving quality of life and reducing hospital readmissions. Today, heart failure is the leading cause of hospitalization in older adults with an estimated 670,000 new cases diagnosed annually. While 90 million Americans have low health literacy that contributes to patient passivity in securing health information, increased adverse events, hospital readmissions, and fatal errors, little is known about the impact of health literacy on HF patients. Hypothesis: 1. Heart failure patients who receive education that is health literacy appropriate will have increased knowledge of disease self-management. 2. Heart failure patients who receive education that is health literacy appropriate will have decreased 30-day heart failure readmission rates. Methods: Forty-five heart failure patients admitted to a single upstate New York hospital were screened for health literacy using the Newest Vital Sign (NVS) tool. When medically stable, health literacy appropriate patient education was provided by a heart failure nurse specialist. Additionally, pre and post testing of patients’ knowledge of heart failure and their treatment were assessed using the Dutch Heart Failure Knowledge Scale and subsequent 30-day heart failure readmission rates were evaluated. Results: Mean age was 77 years; Gender: 44% male, 56% female; Ethnicity: Caucasian 98%, African American 2%; Health literacy screening using the (NVS) assessment tool, suggests limited literacy in 80% of the study group; Despite limited literacy, knowledge of HF increased in 67% of HF patients post individualized HF education; In addition, the 30-day overall readmission rate was only 2%, compared with 15.8% (2009) at this same hospital. Conclusions: This pilot study suggests that health literacy may have an impact on disease self-management and subsequent 30-day overall readmission rates. More importantly, patient’s knowledge of their disease process can be strengthened through evaluation of health literacy and more individualized education by a heart failure nurse specialist. A larger future sample size may further enhance the merits of determining patients’ level of health literacy and the potential impact on HF treatment and readmission rates.
257 Relation of Target Dose Adherence to One Year Mortality in Heart Failure with Reduced Ejection Fraction: A Substudy of SUGAR Jaewon Oh1, Byung-Su Yoo2, Seok-Min Kang1, Dong-Ju Choi3; 1Yonsei University College of Medicine, Seoul, Korea, Republic of; 2Yonsei University Wonju
Severance Christian Hospital, Wonju, Korea, Republic of; University Bundang Hospital, Seongnam, Korea, Republic of
3
Seoul National
Introduction: Guideline-recommended drug target dose was often not reached in patients with heart failure (HF). We hypothesized that target dose adherence could have relations with the prognosis of HF with reduced ejection fraction (HFREF). Methods: The SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR; NCT01390935) trial is a multi-center, retrospective observational study on the subjects admitted with systolic HF (EF!45%) from 23 university hospitals. We analyzed data from SUGAR (n51220, 690 males, 68 6 14 years old, left ventricular EF 29.7 6 8.8 %). Good target dose adherence (TDA) was defined when the dose of each drug was reached to $ 50% of daily target dose. The clinical endpoint was one year all-cause mortality. Results: During follow-up period (median 353, IQR 217-365 days), 80 (6.2 %) patients died. The prevalence of good TDA of ACEi/ARB and BB were 48.0% and 13.5%. Only 5.8% HF patients had good TDA of both drugs. In Kaplan-Meier curves, good TDA ($ 50% of daily target dose) of ACEi/ARB group was associated with longer survival from all-cause mortality (95.7% vs. 92.7%, log rank p 5 0.022) compared to poor TDA (!50% of daily target dose) group. However, good TDA of BB group tended to have longer survival but it was not statistically significant (97.5% vs. 94.3%, log rank p 5 0.132). In adjusted Cox proportional hazard analysis, good TDA of ACEi/ARB was an independent predictor of mortality after adjusting other HF risk factors (HR 0.584, 95% CI 0.344 - 0.991, p 5 0.046). Conclusion: We found that good TDA, especially ACEi/ARB was an independent good prognostic marker in HFREF patients.
258 Noninvasive Wireless Bioimpedance Monitoring Tracks Patients with Healthcare Utilization Following Discharge from Acute Decompensated Heart Failure: Results from the ACUTE Pilot Study Max J. Liebo1, Rodolphe P. Katra2, Niranjan Chakravarthy2, Imad Libbus2, W.H. Wilson Tang1; 1Cleveland Clinic, Cleveland, OH; 2Corventis, Inc., St Paul, MN Background: Heart Failure (HF) remains a significant healthcare challenge characterized by recurrent episodes of acute decompensated HF (ADHF) and frequent hospitalizations. To date, remote monitoring in HF has largely relied on information from implanted devices that are only available in select patients with therapeutic indications or on remote disease management programs with variable outcome benefits. Hypothesis: Physiologic signals derived from a novel, adherent, wireless monitoring system correlate well with patient’s clinical status in-hospital and post-discharge from ADHF. Methods: ACUTE is a multicenter study using the AVIVOÔ Mobile Patient Management System to continuously measure a variety of physiological signals (including heart rate, respiration, activity, and bioimpedance) in patients with EF!40% hospitalized for ADHF. Patients (n560) were monitored during recovery for up to 2 weeks, including 1-week in-hospital and 1-week post-discharge, and followed up by phone at 30 days post-discharge. Physicians were blind to the physiologic signals and followed standard care for management and clinical decision making. Healthcare utilization (HCU) was defined as patients with no improvement during hospitalization to warrant discharge or those with post-discharge worsening that required a significant change in HF medications or rehospitalization. Follow up bioimpedance values were normalized to admission values. Results: In our study cohort (age 60615 years, 79% male, LVEF 2166%), 28% of patients required additional HCU at 30 days. Dichotomizing the cohort into two groups (HCU group vs. No HCU group) revealed no significant differences in baseline characteristics except for larger LV end-diastolic diameter in HCU group (67610 vs. 5668mm, p!0.04). Comparing between HCU group and No HCU group during the in-hospital monitoring period, weight loss (264% vs. 565%) and normalized bioimpedance (99634%
HFSA
S87
level, 68% frail (Fried frailty criteria), 23% with high probability of cognitive impairment (Mini-Cog). Ninety-one percent of subjects were confident in managing medications, though only 11% were able to complete MMAT without errors (Figure). Specifically, 93% were able to read pill bottle labels, 89% were able to open pill bottles, 18% could correctly allocate mock medications into pillbox, and 72% were able to locate correct slot. Of pill allocation failures, 48% failed based on comprehension, 28% failed based on logic, 17% failed due to clerical errors, and 7% refused to complete test. Conclusions: Self-perception and observed ability to manage medications are discordant in older adults hospitalized for HF. This may represent a root cause for downstream medication non-adherence. We describe a novel MMAT that has construct validity in adults hospitalized for HF and may be used in future investigations.
252 Participation in a Multi-Disciplinary Heart Failure Disease Management Program (HFDMP) Minimizes Risk of Aldosterone Antagonist-Induced Hyperkalemia Kristyn Mulqueen, Shawn Anderson, Tamarah Jungklaus, Samantha Malloy, Timothy Cleeton, Jesus Acosta, Jennifer Darago, Richard Schofield; North Florida/ South Georgia Veterans Health System, Gainesville, FL Introduction: Aldosterone antagonists (AA) have been shown to reduce mortality and morbidity in a number of large, randomized controlled trials. Clinical practice guidelines recommend AA therapy for patients with heart failure with reduced ejection fraction (HFrEF), even in those with mild symptoms; however, these agents are often underutilized. Although clinical trials showed relatively low rates of significant hyperkalemia with AA therapy, some observational studies suggest that hyperkalemia occurs more frequently in clinical practice. As a result, some providers may hesitate to prescribe AAs. Hypothesis: Evidence-based prescribing of AAs with appropriate monitoring results in rates of hyperkalemia similar to those seen with standard heart failure (HF) therapy without an AA. Methods: A retrospective review of HF patients followed in a multi-disciplinary Heart Failure Disease Management Program (HFDMP) was performed to compare the incidence of hyperkalemia in patients managed with HF pharmacotherapy with AA (AA therapy group) or without AA (standard therapy group). Inpatient and outpatient medical records were reviewed to identify episodes of hyperkalemia occurring while patients were enrolled in the HFDMP. Hyperkalemia was classified as clinical (K $ 6 mmol/L) or subclinical (6 mmol/L O K $ 5.5 mmol/L). Hyperkalemic events were excluded if the blood sample was hemolyzed. One hundred fifty patients were needed in each group to have 80% power to detect a difference in the rate of hyperkalemia, using expected rates of 15% in the AA therapy group and 2% in the standard therapy group. Results: A total of 300 patients were included in the study. Clinical hyperkalemia occurred in 5 (3.3%) patients in the AA therapy group and 6 (4%) patients in the standard therapy group (p50.76). Subclinical hyperkalemia occurred in 15 (10%) patients in the AA therapy group and 22 (15%) patients in the standard therapy group (p50.22). The observed rate of any hyperkalemia for patients on AA therapy and standard therapy was 13.3% and 18.7%, respectively (p50.21). Conclusions: We found no statistically significant difference in the rate of hyperkalemia between groups of HFDMP patients treated with AA compared with those receiving standard HF therapy. Appropriate patient selection, close laboratory monitoring and follow-up allow for the safe use of AA therapy in patients with HFrEF.
253 Patients Hospitalized for Heart Failure Have Difficulties Managing Medications Despite Reported Self-Confidence Erik H. Howell1, Alpana Senapati1, Eiran Z. Gorodeski2; 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH Introduction: Medication non-adherence is prevalent and associated with poor outcomes. Root causes are not clearly understood. The ability of patients to manage their own medications is not routinely assessed at time of hospital discharge. We developed a novel medication management assessment tool (MMAT) and applied it to patients hospitalized for HF. Hypothesis: Patients hospitalized for HF have under recognized poor medication self-management skills. Methods: We prospectively enrolled inpatients transitioning from hospital-to-home after hospitalization for HF. Prior to discharge, MMAT was deployed under direct observation. MMAT involved a series of tasks focused on allocating mock medications into a weekly pillbox. Prior to testing subjects were asked “Do you feel confident managing your medications on a daily basis?” Subjects were then provided 5 pill bottles representing common HF medications, each filled with 30 mock pills. Four components were assessed pass/ fail: (1) ability to read pill bottle label, verbally stating medication name and instructions; (2) ability to open pill bottle; (3) ability to allocate pills into pillbox correctly; (4) ability to locate specific slot in pillbox. Failure to allocate pills correctly was further subdivided into four categories: (1) Failure in comprehension (no discernible method of allocating pills); (2) Failure in logic (method of allocating pills has repeated error); (3) Clerical errors (appropriate comprehension and logic but !25% of pills allocated incorrectly) and (4) Refusal to complete MMAT after initiation. Results: Of 94 subjects approached 56 consented. Mean age was 77 [range 66-92], 73% male, 64% Caucasian, 32% with HFPEF (LVEF$50%), 30% with low health literacy
254 Outpatient Ultrafiltration as an Alternative to Hospitalization for Mild to Moderate Decompensated Heart Failure Sitaramesh Emani1, Jennifer Host1, Tara L. Baxter1, Todd Yamokoski1, Matthew R. Potter2, Kyle Porter3, Garrie Haas1; 1The Ohio State University, Columbus, OH; 2The Ohio State University, Columbus, OH; 3The Ohio State University, Columbus, OH Background: We previously reported data suggesting feasibility and safety of an outpatient ultrafiltration (UF) protocol to treat mild-moderate acute decompensated heart failure (ADHF). In follow up, we tracked 30-day outcomes following outpatient UF with the hypothesis that outcomes would mirror those of ADHF hospitalizations. Furthermore, we propose that outpatient UF may be a cost-effective alternative to hospitalization in this highly selected population. Methods: We retrospectively analyzed the medical record of consecutive patients who underwent outpatient UF per our established protocol. Treatment characteristics and efficacy were recorded. Unplanned hospitalizations or emergency room visits were tracked for 30 days. Finally, the cost of each outpatient UF treatment was compared to the average cost of an ADHF admission. Results: A total of 37 treatment episodes were identified. Each episode met criteria of outpatient UF based on our previously presented criteria. Demographic data are shown in table 1. Weight decreased by 7.1 kg (95% CI 5.4, 8.8) and creatinine changed by 0.01 (CI -0.10, 0.11). The rate of unplanned admission or ER visits at 30 days postUF was 24% (CI 10, 44%), which is comparable to a national ADHF readmission rate of 27%. The average charge for outpatient UF was $25,500 per treatment ($11,100/ day), which is less than typical inpatient charges for an ADHF hospitalization at our institution (based on a national average length of stay of 6.4 days). Reimbursement for outpatient at present is highly variable based on payer source. Conclusions: Outpatient UF can serve as an alternative to inpatient admission for selected cases of Demographic Data Average Age
59.6 yrs
Male ICM HFpEF Daily furosemide equivalent Thiazide use Number of UF days/episode
78% 65% 11% 161.1 mg 38% 2.3
S88 Journal of Cardiac Failure Vol. 19 No. 8S August 2013 mild-moderate ADHF. Intermediate outcomes are similar to reported rates for hospitalization, but outpatient UF may represent a cost effective way to provide therapy.
255 Impact of Digoxin Loading on Hemodynamics in Advanced Low Output Heart Failure: A Case-Series Review Rajakrishnan Vijayakrishnan1, W.H. Wilson Tang2, Maria Mountis2, David Taylor2, Randall Starling2, Mazen Hanna2; 1Geisinger Medical Center, Danville, PA; 2 Cleveland Clinic Foundation, Cleveland, OH Introduction: Cardiac glycosides are the only available oral agents which have positive inotropic effects and do not increase myocardial oxygen consumption. We conducted a single center study of acute intravenous digoxin loading in patients with low output decompensated heart failure (HF) with hemodynamic monitoring. Hypothesis: Digoxin loading is safe and effective in improving cardiac index (CI) and decreasing the need for IV inotropic support in low output decompensated HF. Methods: A total of 10 patients with low output HF monitored with a Swan Ganz catheter were loaded with 1 mg of Digoxin over a 24 hour period. Loading dose was given intravenously as 0.5 mg followed by 0.25 mg in six hours and then 0.25 mg six hours later. Hemodynamic variables were obtained before and after digoxin loading. Safety end points included atrial and ventricular arrhythmias and digoxin level at 72 hours after loading. Results: Baseline echocardiographic and hemodynamic variables were consistent with advanced HF, with a mean LVEF of 15 +/- 5 %, a baseline mean CI of 1.67 L/min/m2 and a mean PCWP of 27.4 mm Hg. After Digoxin loading, CI improved by a mean of 60.1 % (0% to 135.7%) and PCWP decreased by 38.2% (11% to 50%). Mean arterial pressure remained stable along with mean heart rate change of -2.1 % (-20. 6 % to +11.4%). Four patients who were IV inotrope dependent were successfully transitioned off IV inotropes to oral agents. None of the patients had any significant atrial or ventricular arrhythmias during the ICU stay. Digoxin levels were consistently below 2 ng/ml at 72 hours post digoxin loading. Conclusions: We demonstrated the efficacy and safety of IV digoxin loading in acutely improving cardiac index and facilitating weaning off IV inotropes in the setting of low output decompensated HF.
256 The Intersection of Knowledge Transfer and Health Literacy in Reducing Readmission Rates for Heart Failure John D. Filippone1, Madeline Cafiero2, Kathleen A. Kelly2, Cathleen M. Daley1; 1St Peter’s Health Partners, Albany, NY; 2The Sage Colleges, Troy, NY Introduction: Heart failure is a complex chronic disease requiring an acceptable level of health literacy to better integrate knowledge and skills related to self-efficacy and disease management. The aim of this study is to show that testing for health literacy through a nurse-led inpatient educational program will enhance patients’ understanding of chronic illness and better enable them to understand lifestyle changes necessary for improving quality of life and reducing hospital readmissions. Today, heart failure is the leading cause of hospitalization in older adults with an estimated 670,000 new cases diagnosed annually. While 90 million Americans have low health literacy that contributes to patient passivity in securing health information, increased adverse events, hospital readmissions, and fatal errors, little is known about the impact of health literacy on HF patients. Hypothesis: 1. Heart failure patients who receive education that is health literacy appropriate will have increased knowledge of disease self-management. 2. Heart failure patients who receive education that is health literacy appropriate will have decreased 30-day heart failure readmission rates. Methods: Forty-five heart failure patients admitted to a single upstate New York hospital were screened for health literacy using the Newest Vital Sign (NVS) tool. When medically stable, health literacy appropriate patient education was provided by a heart failure nurse specialist. Additionally, pre and post testing of patients’ knowledge of heart failure and their treatment were assessed using the Dutch Heart Failure Knowledge Scale and subsequent 30-day heart failure readmission rates were evaluated. Results: Mean age was 77 years; Gender: 44% male, 56% female; Ethnicity: Caucasian 98%, African American 2%; Health literacy screening using the (NVS) assessment tool, suggests limited literacy in 80% of the study group; Despite limited literacy, knowledge of HF increased in 67% of HF patients post individualized HF education; In addition, the 30-day overall readmission rate was only 2%, compared with 15.8% (2009) at this same hospital. Conclusions: This pilot study suggests that health literacy may have an impact on disease self-management and subsequent 30-day overall readmission rates. More importantly, patient’s knowledge of their disease process can be strengthened through evaluation of health literacy and more individualized education by a heart failure nurse specialist. A larger future sample size may further enhance the merits of determining patients’ level of health literacy and the potential impact on HF treatment and readmission rates.
257 Relation of Target Dose Adherence to One Year Mortality in Heart Failure with Reduced Ejection Fraction: A Substudy of SUGAR Jaewon Oh1, Byung-Su Yoo2, Seok-Min Kang1, Dong-Ju Choi3; 1Yonsei University College of Medicine, Seoul, Korea, Republic of; 2Yonsei University Wonju
Severance Christian Hospital, Wonju, Korea, Republic of; University Bundang Hospital, Seongnam, Korea, Republic of
3
Seoul National
Introduction: Guideline-recommended drug target dose was often not reached in patients with heart failure (HF). We hypothesized that target dose adherence could have relations with the prognosis of HF with reduced ejection fraction (HFREF). Methods: The SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR; NCT01390935) trial is a multi-center, retrospective observational study on the subjects admitted with systolic HF (EF!45%) from 23 university hospitals. We analyzed data from SUGAR (n51220, 690 males, 68 6 14 years old, left ventricular EF 29.7 6 8.8 %). Good target dose adherence (TDA) was defined when the dose of each drug was reached to $ 50% of daily target dose. The clinical endpoint was one year all-cause mortality. Results: During follow-up period (median 353, IQR 217-365 days), 80 (6.2 %) patients died. The prevalence of good TDA of ACEi/ARB and BB were 48.0% and 13.5%. Only 5.8% HF patients had good TDA of both drugs. In Kaplan-Meier curves, good TDA ($ 50% of daily target dose) of ACEi/ARB group was associated with longer survival from all-cause mortality (95.7% vs. 92.7%, log rank p 5 0.022) compared to poor TDA (!50% of daily target dose) group. However, good TDA of BB group tended to have longer survival but it was not statistically significant (97.5% vs. 94.3%, log rank p 5 0.132). In adjusted Cox proportional hazard analysis, good TDA of ACEi/ARB was an independent predictor of mortality after adjusting other HF risk factors (HR 0.584, 95% CI 0.344 - 0.991, p 5 0.046). Conclusion: We found that good TDA, especially ACEi/ARB was an independent good prognostic marker in HFREF patients.
258 Noninvasive Wireless Bioimpedance Monitoring Tracks Patients with Healthcare Utilization Following Discharge from Acute Decompensated Heart Failure: Results from the ACUTE Pilot Study Max J. Liebo1, Rodolphe P. Katra2, Niranjan Chakravarthy2, Imad Libbus2, W.H. Wilson Tang1; 1Cleveland Clinic, Cleveland, OH; 2Corventis, Inc., St Paul, MN Background: Heart Failure (HF) remains a significant healthcare challenge characterized by recurrent episodes of acute decompensated HF (ADHF) and frequent hospitalizations. To date, remote monitoring in HF has largely relied on information from implanted devices that are only available in select patients with therapeutic indications or on remote disease management programs with variable outcome benefits. Hypothesis: Physiologic signals derived from a novel, adherent, wireless monitoring system correlate well with patient’s clinical status in-hospital and post-discharge from ADHF. Methods: ACUTE is a multicenter study using the AVIVOÔ Mobile Patient Management System to continuously measure a variety of physiological signals (including heart rate, respiration, activity, and bioimpedance) in patients with EF!40% hospitalized for ADHF. Patients (n560) were monitored during recovery for up to 2 weeks, including 1-week in-hospital and 1-week post-discharge, and followed up by phone at 30 days post-discharge. Physicians were blind to the physiologic signals and followed standard care for management and clinical decision making. Healthcare utilization (HCU) was defined as patients with no improvement during hospitalization to warrant discharge or those with post-discharge worsening that required a significant change in HF medications or rehospitalization. Follow up bioimpedance values were normalized to admission values. Results: In our study cohort (age 60615 years, 79% male, LVEF 2166%), 28% of patients required additional HCU at 30 days. Dichotomizing the cohort into two groups (HCU group vs. No HCU group) revealed no significant differences in baseline characteristics except for larger LV end-diastolic diameter in HCU group (67610 vs. 5668mm, p!0.04). Comparing between HCU group and No HCU group during the in-hospital monitoring period, weight loss (264% vs. 565%) and normalized bioimpedance (99634%