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Prognostic Implications of Atrial Fibrillation on Patients Admitted with Acute Decopensated Heart Failure and Acute Kidney Injury
S58 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 dently associated with increased mortality [adjusted OR 1.39 (1.07,1.79), p-0.011] in patients hospitalized with AP. Conclusion: Our study showed that patients with AP associated with CHF have significantly higher mortality in comparison with those without CHF. While acute respiratory distress syndrome is a known complication of AP, concomitant CHF was shown to have a higher rate of respiratory failure, requiring intubation and mechanical ventilation. Volume resuscitation in patients with CHF and AP can be challenging, as there is a very fine balance to tip them from euvolemic to volume overload state. Future studies are needed to determine methods to improve volume resuscitation in these patients.
148 Severe Right Ventricular Dysfunction Predicts Failure of Intra-Aortic Balloon Pump Hemodynamic Support in Cardiogenic Shock Jana P. Lovell, M. Imran Aslam, Steven P. Schulman, Steven Hsu; Johns Hopkins University School of Medicine, Baltimore, MD Introduction: We previously showed that ischemic history and low left ventricular cardiac power index (LVCPI) predict failure of intra-aortic balloon pump (IABP) hemodynamic support in cases of acute decompensated heart failure complicated by cardiogenic shock. We hypothesized that right ventricular (RV) systolic dysfunction would further impact the adequacy and outcomes of IABP hemodynamic support. Methods: We retrospectively studied 74 patients who underwent IABP insertion for treatment of cardiogenic shock not related to acute myocardial infarction. Severity of RV systolic dysfunction, based on echocardiographic assessment, ranged from none to severe. Poor outcomes from IABP support included death or need for unplanned upgrade of mechanical circulatory support. Successful outcomes included bridge to recovery, transplant, or left ventricular assist device. Multivariable regression and Cox proportional hazard ratios were also used to study outcomes. Results: Severe RV systolic dysfunction on echocardiogram was found in 10 patients (13.5%). Severe RV dysfunction, when compared to patients with no or mild RV dysfunction, was associated with increased right atrial pressure (RAP) (20.6§6 vs. 16.2§5.9 mmHg, p=0.04) and lower RV stroke work index (3.2§2.0 vs. 5.5§3.4 g/m, p=0.046) at time of IABP placement. After 48 hours of IABP support, patients with severe RV dysfunction continued to have higher RAP (18.9§8.5 vs. 12.2§4.7 mmHg, p=0.03), as well as worsened pulmonary artery pulsatility index (1.3§0.7 vs. 2.6§2.4, p=0.048) and RAP/pulmonary capillary wedge ratio (1.1§0.7 vs. 0.7§0.3, p=0.01). Severe RV systolic dysfunction independently predicted poor outcomes (OR 8.5, p=0.01), even when adjusted for LVCPI and ischemic history. An IABP failure risk score using all 3 variables (severe RV dysfunction, LVCPI, and ischemic history) predicted 28-day outcomes with excellent discrimination (Figure 1). Conclusions: Severe RV systolic dysfunction corresponds with poor right-sided hemodynamics at baseline and following IABP support, and may predict failure of IABP hemodynamic support. Severe RV systolic dysfunction complicating cardiogenic shock likely warrants up-front consideration of biventricular support instead of IABP alone.
majority agreed that pain in HF patients was related to anxiety, depression, fatigue and unplanned hospitalization, and pain should be individually assessed and managed. More than 80% of them thought pain management practice in HF patients should be improved, 78.1% were interested in getting more information and online education module was the most preferable approach. Lack pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding to opioid use in pain management in HF. The gaps of managing pain in HF patients included lack knowledge of opioid use, lack consideration and awareness of pain, no clinical guidelines of pain assessment and treatment, and complicated pain management with multiple chronic conditions. Conclusions: The impact of pain, individually assessment and management of pain in HF patients were well perceived by nurses, whereas improvement in pain management practice in HF patients are needed. Concerns regarding to opioid use and gaps in pain management of HF patients should be addressed.
150 Prognostic Implications of Atrial Fibrillation on Patients Admitted with Acute Decopensated Heart Failure and Acute Kidney Injury Haitham Mazek, Sabry Omar, Sharma Prabhakar; Texas Tech University Health Sciences Center, Lubbock, TX Introduction: Patients with acute heart failure (AHF) & acute kidney injury (AKI) have increased hospital mortality and readmissions. The impact of atrial fibrillation (AF) in these patients has not been well studied. We examined the hypothesis that the presence of AF in patients with AHF and AKI will further increase mortality and rates of readmission. Methods: Medical records of patients who were admitted with AHF and AKI between 2008 and 2010 (n=244) were reviewed. The patients were divided into two groups: patients with AHF and AKI with presence of AF (N= 66), and absence of AF (N=178). Presence of AF was confirmed using electrocardiogram on admission. AKI was defined as a rise of serum creatinine > 0.3 mg/dL above their baseline. Results: We studied 244 patients with AHF and AKI (121 male and 123 female) with a mean age of 64.12 §16.4; 27 % of patients had AF on admission. The 30 days in-hospital mortality, 90-days readmission and length of hospital stay were significantly higher in patients with AF compared to patients without AF (Table 1). In the multivariate logistic regression model the only independent predictors of mortality were left ventricular ejection fraction (odds ratio 0.963; 95 % CI 0.930 to 0.997; P = 0.032) and the use of angiotensin converting enzyme inhibitors (odds ratio 0.225; 95 % CI 0.066 to 0.763; P = 0.017). Conclusions: The presence of AF in patients with AHF and AKI is associated with increased mortality, readmission rates and length of hospital stay. Higher LVEF and the use of ACE inhibitors predicted better survival.
151 149 Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception Jie Chen, Stephen Walsh, Colleen Delaney, Xiaomei Cong; University of Connecticut, Storrs, CT Background: Over 50% of patients with heart failure (HF) report suffering from pain and pain related burdens; however, pain in HF patients has not been recognized and well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception. Aims: To investigate nurses’ perception of pain management in HF patients. Methods: Members of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey. Results: A total of 147 nurses responded and completed the survey. The
Beta-Blocker Cessation in Stable Outpatients with Heart Failure with a Preserved Ejection Fraction Lakshmi Nambiar, Daniel Silverman, Peter VanBuren, Martin LeWinter, Markus Meyer; University of Vermont Medical Center, Burlington, VT Background: Beta-blockers are frequently administered to patients with heart failure with a preserved ejection fraction (HFpEF), but their effectiveness is unproven. In patients with a normal left ventricular EF and hypertension (HTN) and/or coronary artery disease (CAD), there are emerging concerns that betablockers are associated with adverse outcomes, including heart failure. In view of these concerns, we discontinued or discontinued and replaced beta-blockers in a series of stable outpatients with HFpEF. Methods: Beta-blockers were discontinued in 22 patients with HF and an EF50%. NT-proBNP levels were obtained before and after beta-blocker cessation. Baseline clinical characteristics, echocardiography data, medications and beta-blocker substitutions were tabulated.
148 Severe Right Ventricular Dysfunction Predicts Failure of Intra-Aortic Balloon Pump Hemodynamic Support in Cardiogenic Shock Jana P. Lovell, M. Imran Aslam, Steven P. Schulman, Steven Hsu; Johns Hopkins University School of Medicine, Baltimore, MD Introduction: We previously showed that ischemic history and low left ventricular cardiac power index (LVCPI) predict failure of intra-aortic balloon pump (IABP) hemodynamic support in cases of acute decompensated heart failure complicated by cardiogenic shock. We hypothesized that right ventricular (RV) systolic dysfunction would further impact the adequacy and outcomes of IABP hemodynamic support. Methods: We retrospectively studied 74 patients who underwent IABP insertion for treatment of cardiogenic shock not related to acute myocardial infarction. Severity of RV systolic dysfunction, based on echocardiographic assessment, ranged from none to severe. Poor outcomes from IABP support included death or need for unplanned upgrade of mechanical circulatory support. Successful outcomes included bridge to recovery, transplant, or left ventricular assist device. Multivariable regression and Cox proportional hazard ratios were also used to study outcomes. Results: Severe RV systolic dysfunction on echocardiogram was found in 10 patients (13.5%). Severe RV dysfunction, when compared to patients with no or mild RV dysfunction, was associated with increased right atrial pressure (RAP) (20.6§6 vs. 16.2§5.9 mmHg, p=0.04) and lower RV stroke work index (3.2§2.0 vs. 5.5§3.4 g/m, p=0.046) at time of IABP placement. After 48 hours of IABP support, patients with severe RV dysfunction continued to have higher RAP (18.9§8.5 vs. 12.2§4.7 mmHg, p=0.03), as well as worsened pulmonary artery pulsatility index (1.3§0.7 vs. 2.6§2.4, p=0.048) and RAP/pulmonary capillary wedge ratio (1.1§0.7 vs. 0.7§0.3, p=0.01). Severe RV systolic dysfunction independently predicted poor outcomes (OR 8.5, p=0.01), even when adjusted for LVCPI and ischemic history. An IABP failure risk score using all 3 variables (severe RV dysfunction, LVCPI, and ischemic history) predicted 28-day outcomes with excellent discrimination (Figure 1). Conclusions: Severe RV systolic dysfunction corresponds with poor right-sided hemodynamics at baseline and following IABP support, and may predict failure of IABP hemodynamic support. Severe RV systolic dysfunction complicating cardiogenic shock likely warrants up-front consideration of biventricular support instead of IABP alone.
majority agreed that pain in HF patients was related to anxiety, depression, fatigue and unplanned hospitalization, and pain should be individually assessed and managed. More than 80% of them thought pain management practice in HF patients should be improved, 78.1% were interested in getting more information and online education module was the most preferable approach. Lack pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding to opioid use in pain management in HF. The gaps of managing pain in HF patients included lack knowledge of opioid use, lack consideration and awareness of pain, no clinical guidelines of pain assessment and treatment, and complicated pain management with multiple chronic conditions. Conclusions: The impact of pain, individually assessment and management of pain in HF patients were well perceived by nurses, whereas improvement in pain management practice in HF patients are needed. Concerns regarding to opioid use and gaps in pain management of HF patients should be addressed.
150 Prognostic Implications of Atrial Fibrillation on Patients Admitted with Acute Decopensated Heart Failure and Acute Kidney Injury Haitham Mazek, Sabry Omar, Sharma Prabhakar; Texas Tech University Health Sciences Center, Lubbock, TX Introduction: Patients with acute heart failure (AHF) & acute kidney injury (AKI) have increased hospital mortality and readmissions. The impact of atrial fibrillation (AF) in these patients has not been well studied. We examined the hypothesis that the presence of AF in patients with AHF and AKI will further increase mortality and rates of readmission. Methods: Medical records of patients who were admitted with AHF and AKI between 2008 and 2010 (n=244) were reviewed. The patients were divided into two groups: patients with AHF and AKI with presence of AF (N= 66), and absence of AF (N=178). Presence of AF was confirmed using electrocardiogram on admission. AKI was defined as a rise of serum creatinine > 0.3 mg/dL above their baseline. Results: We studied 244 patients with AHF and AKI (121 male and 123 female) with a mean age of 64.12 §16.4; 27 % of patients had AF on admission. The 30 days in-hospital mortality, 90-days readmission and length of hospital stay were significantly higher in patients with AF compared to patients without AF (Table 1). In the multivariate logistic regression model the only independent predictors of mortality were left ventricular ejection fraction (odds ratio 0.963; 95 % CI 0.930 to 0.997; P = 0.032) and the use of angiotensin converting enzyme inhibitors (odds ratio 0.225; 95 % CI 0.066 to 0.763; P = 0.017). Conclusions: The presence of AF in patients with AHF and AKI is associated with increased mortality, readmission rates and length of hospital stay. Higher LVEF and the use of ACE inhibitors predicted better survival.
151 149 Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception Jie Chen, Stephen Walsh, Colleen Delaney, Xiaomei Cong; University of Connecticut, Storrs, CT Background: Over 50% of patients with heart failure (HF) report suffering from pain and pain related burdens; however, pain in HF patients has not been recognized and well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception. Aims: To investigate nurses’ perception of pain management in HF patients. Methods: Members of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey. Results: A total of 147 nurses responded and completed the survey. The
Beta-Blocker Cessation in Stable Outpatients with Heart Failure with a Preserved Ejection Fraction Lakshmi Nambiar, Daniel Silverman, Peter VanBuren, Martin LeWinter, Markus Meyer; University of Vermont Medical Center, Burlington, VT Background: Beta-blockers are frequently administered to patients with heart failure with a preserved ejection fraction (HFpEF), but their effectiveness is unproven. In patients with a normal left ventricular EF and hypertension (HTN) and/or coronary artery disease (CAD), there are emerging concerns that betablockers are associated with adverse outcomes, including heart failure. In view of these concerns, we discontinued or discontinued and replaced beta-blockers in a series of stable outpatients with HFpEF. Methods: Beta-blockers were discontinued in 22 patients with HF and an EF50%. NT-proBNP levels were obtained before and after beta-blocker cessation. Baseline clinical characteristics, echocardiography data, medications and beta-blocker substitutions were tabulated.