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The Impact of an Advance Care Planning Intervention for Patients with Heart Failure
S60 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 continuous and categorical variables, respectively. Results: Median age was 59 years, 22.2% were female, 72.3% were non-White, and median BMI was 25.4. The majority of VADs were Heartmate II devices. Fewer than half of study participants (7/18) completed all 36 scheduled CR sessions. Among those who did not complete CR (N=11) 4 participants were transplanted, 5 stopped due to medical reasons, and 2 stopped due to social barriers. Baseline demographics, medications, and comorbidities were similar between those who did and did not complete CR (Table). VAD recipients with more severe functional impairment based on pre-CPET measures were significantly less likely to complete CR. Conclusions: Our study demonstrates the feasibility of CR implementation among VAD recipients in a diverse urban cohort, although a considerable proportion failed to complete all 36 scheduled sessions. Among those who did not complete CR, functional capacity was lower at baseline. More work is warranted to determine the optimal timing and CR regimen for VAD recipients.
155 Influence of a Novel Multidisciplinary Cognitive Impairment Intervention on Post-Acute Care in an Inpatient Community-Based HFrEF Cohort Vijay U. Rao1, Atul R. Chugh1, Kathy Stark1, Donna McClory1, Eiran Z. Gorodeski2; 1 Franciscan Health, Indiana Heart Physicians, Indianapolis, IN; 2Cleveland Clinic, Cleveland, OH Background: Cognitive impairment (CI) is a strong predictor of six-month mortality and risk for re-admission in older hospitalized heart failure (HF) patients. We sought to develop a novel, multidisciplinary CI inpatient intervention to improve post-acute care discharge planning and reduce 30-day hospital re-admissions. Methods: From July 2016 to July 2018 at a large, community-based hospital, we developed a CI inpatient screening program using the Mini-Cog test for eligible patients over the age of 65 admitted with a primary diagnosis of HF. The Mini-Cog is a three word recall and clock drawing test, scored between 0 and 5 points. A score of 2 or below identifies CI. In May 2017, Mini-Cog (+) patients received a multidisciplinary CI intervention led by palliative care nurses and speech therapists which included: a) family meeting b) goals of care discussion c) family-directed HF education and d) speech therapy evaluation. We compared the pre-intervention cohort (10 months prior to intervention) with the post-intervention cohort (15 months after intervention) with respect to discharge disposition and 30-day re-admission rates. Results: We screened 740 patients for CI, of which 11.4% were Mini-Cog (+). In Mini-Cog (+) patients, the CI intervention increased the percentage of home health discharges (46% vs 20%, p=0.02, OR 3.4) and decreased the percentage of home discharges (44% vs 15%, p=0.008, OR 0.23), while rates of skilled nursing and hospice discharges were not significantly different (29% vs 26%, p=0.93 and 7% vs 8%, p=1.0), respectively). In the Mini-Cog (-) patients, there were no significant differences in pre vs post intervention cohort discharge disposition. In the combined pre and post intervention cohorts, a greater percentage of Mini-cog (+) patients were discharged to skilled nursing facilities and hospice compared to Mini-cog (-) patients (36.9% vs 19.8%, P < 0.001). While the Mini-Cog (-) patient 30-day re-admission rate in the pre and post intervention cohorts were similar (18% vs 17%), the Mini-cog (+) patient 30-day readmission rate was numerically lower in the post-intervention cohort compared to the pre-intervention cohort (15.3% vs 20.0%, P=0.29). Conclusions: CI represents an important marker of HF post-acute care morbidity and mortality. Our CI multi-disciplinary intervention had a significant impact on discharge disposition with increased utilization of home health services. While not achieving statistical significance likely due to inadequate power, our intervention numerically lowered rates of 30-day re-admissions in a high-risk CI impaired population. Moreover, re-admission rates were similar to those noted in the Mini-Cog (-) group in this high-risk population. Hence, we believe these data justify further validation of this novel, multi-disciplinary approach in a larger multi-center study.
initial symptoms included cardiac (n=40, 59%), peripheral or autonomic neuropathy (n=16, 24%), and carpal tunnel syndrome (n=5, 7%). Cardiac was predominantly the initial symptom experienced by patients with wild type ATTR amyloidosis (75%) while cardiac (48%) or neuropathy (38%) were the initial symptoms experienced most often by patients with hereditary ATTR amyloidosis. Only one-quarter (n=17) of patients received their diagnosis within 6 months of their initial symptom onset (mean=3.6 years), and 5 (7%) patients were identified through genetic testing before symptom onset. Twenty-two (32%) patients reported seeing 6 or more HCPs before receiving their ATTR amyloidosis diagnosis; more than two-thirds (n=47, 69%) of the sample reported seeing 3 or more HCPs before diagnosis. Patients commonly visited primary care providers (n=52) and cardiologists (n=51) with a median of 3 visits to primary care providers and 2 visits to cardiologists before receiving their diagnosis; however, cardiologists most often made or confirmed final diagnoses of ATTR amyloidosis (n=49, 72%). Of the reported diagnostic procedures, the most common were echocardiogram (n=50), biopsy (n=45), MRI or CMR (n=34), genetic testing (n=30), cardiac biomarkers (n=18); and radionuclide imaging (PYP/DPD; n=13); among biopsy locations, cardiac (n=29) and fat pad (n=22) biopsies were the most frequently reported. Conclusions: These results indicate that the journey to a diagnosis for patients with ATTR-CM is complicated and delays in diagnosis are common. Increased awareness of ATTR amyloidosis among cardiologists may help to raise early suspicion, reduce the time to an accurate diagnosis, and initiate early treatment.
157 Takotsubo Cardiomyopathy Mortality and Costs in Cancer, PCI, and Racial Disparities: Propensity Score Adjusted Machine Learning Guided Analysis of 6+ Million Inpatient Admissions Phi Tran1, Dominique Monlezun2, Sovik De Sirkar2, Gloria Iliescu1, Peter Kim1, Juan Lopez-Mattei1, Jean-Bernard Durand1, Nicolas Palaskas1, Cezar Iliescu1; 1The University of Texas MD Anderson Cancer Center, Houston, TX; 2The University of Texas Health Science Center at Houston, Houston, TX Introduction: Takotsubo Cardiomyopathy (TTC) remains an elusive diagnosis complicating prompt and appropriate care for patients presenting to the hospital with heart failure symptoms. This study demonstrates the first multi-center analysis of TTC and percutaneous coronary intervention (PCI) mortality, costs, and disparities. Methods: The backward propagation neural network supervised machine learning algorithm supported multivariable regression and propensity score matched analysis of mortality and total hospital costs for TTC in this case-control study of the 2016 National Inpatient Sample (NIS). Results: Of the 6,039,969 hospitalizations, 0.13% were diagnosed with TTC, 132,222 (2.19%) died inpatient, and the median total costs were $29,143 (range $15,587-56,287). In multivariable regression fully adjusting for age, race, and mortality risk, PCI for TTC patients significantly reduced mortality (OR 0.53, p<0.001) and costs (-$62,232.82, p<0.001). In propensity score matched analysis in TTC patients, PCI significantly reduced mortality by 7.30% (p<0.001). Among TTC patients, there were significant income disparities in mortality (versus 1st quartile median income: 2nd [OR1.72, p=0.001], 3rd [OR 1.58, p=0.005], and 4th [OR 1.52, p=0.012]). Conclusions: This is the first known nationally-representative machine learning and propensity score-augmented analysis demonstrating that PCI significantly reduces mortality and inpatient costs for TTC. Since TTC by definition should not have obstructive coronary artery disease to explain the wall motion abnormalities, our findings suggest TTC is misdiagnosed in many inpatient hospitalizations. This helps explain the improvement in mortality that is likely revascularization of ischemic heart disease that caused heart failure with reduced ejection fraction. In addition, this analysis showed that TTC itself has significant mortality disparities based on income.
158 156 Characterizing the Journey to Diagnosis for Patients with Transthyretin Amyloidosis and Accompanying Congestive Heart Failure Asia Sikora Kessler1, Aaron Yarlas1, Michael Pollock2, Spencer Guthrie3, Kristen L. McCausland1; 1Optum, Johnston, RI; 2Akcea Therapeutics, Carlsbad, CA; 3Biopharma Strategic Consulting, LLC, San Francisco, CA Introduction: Transthyretin (ATTR) amyloidosis is a rare, systemic, progressive, and fatal condition in which misfolded transthyretin proteins deposit as amyloid in nervous, cardiac, and other tissue. The deposition of amyloid in cardiac tissue results in cardiomyopathy (CM). Hypothesis: The journey to diagnosis for patients with ATTR amyloidosis and accompanying CM (ATTR-CM) is long and complex and may result in delayed treatment initiation due to misdiagnosis. Methods: Adult patients in the US and Canada with ATTR amyloidosis were enrolled in an online, longitudinal observational survey study. Analyses were based on initial survey responses from a subset of patients with self-reported cardiac involvement (n=68). Journey to diagnosis was assessed in terms of: age at symptom onset, types of initial symptoms, time to diagnosis, number and types of healthcare providers (HCPs) consulted, frequency of visits to HCPs prior to diagnosis, types of HCPs who provided diagnosis, and types of diagnostic procedures performed by HCPs while seeking a diagnosis. Results were summarized descriptively. Results and Conclusions: On average, patients were 60.9 years of age at the time of symptom onset. Self-reported
The Impact of an Advance Care Planning Intervention for Patients with Heart Failure Therese C. Prentice1, Robin Lawson2; 1Abington Hospital Jefferson Health, Abington, PA; 2University of Alabama, Tuscaloosa, AL Introduction: Patients with chronic heart failure face a life-limiting disease trajectory, yet many have not addressed end-of-life planning. The ideal method to assist patients with advance directive (AD) completion and end-of-life goal setting is not clearly established. Hypothesis: A nurse practitioner led, interactive education program for patients hospitalized with acute decompensated heart failure utilizing the Institute of Healthcare Improvement tool, The Conversation Project, will improve patient attitudes regarding advance directives, increase completion of advance directive documents and increase discussion of end-of-life goals with significant others and health care providers. Methods: A convenience sample of 30 patients hospitalized with acute decompensated heart failure who had not completed AD was used. Study participants completed the Advance Directive Attitude Survey (ADAS) prior to reviewing The Conversation Project materials and receiving education from a nurse practitioner trained in end-of-life counseling. A comparison of pre-/post-intervention outcome measures included ADAS scores, completion of AD, establishment of surrogate decision maker and discussion of end-of-life goals with provider and significant others. Results: All study participants (n=30) had positive ADAS scores prior to the intervention. Post intervention outcomes were measured 30 days after the intervention in 25 participants (83%). ADAS scores remained positive with no
The 23rd Annual Scientific Meeting HFSA significant change (p=0.53). A noteworthy 64% (n=16) of participants discussed AD with significant other, 40% (n=10) established surrogate decision maker and 28% (n=7) completed AD. Only 12% (n=3) discussed AD with a health care provider. Conclusions: A nurse practitioner led advance care planning program using The Conversation Project showed clinically significant, but limited outcome improvement. A positive attitude regarding AD was not associated with completion of AD documents or discussion of end-of-life goals with significant others or health care providers. Further study of measures to improve the AD completion process, including programs targeting the outpatient population over a longer time frame and strategies to increase discussion with health care providers is recommended.
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patients also received PCI resulting in improved mortality and total costs suggests that ischemic heart disease rather than TTC was the culprit. In addition, the thrombocytopenic patients with acute on chronic heart failure that received PCI and were labeled as TTC also had decreased total costs. This study may help provide cardiologists clinically relevant predictors of TTC and its outcomes to risk stratify patients. In addition, it suggests that despite thrombocytopenia providers should not be quick to label patients with TTC but rather consider invasive workup with possible PCI that may decrease costs of inpatient admissions.
160 Transitioning Patients to Oral Diuretics 24 Hours before Discharge from Heart Failure Hospitalization Does Not Improve 30 Day Outcomes Stephen Schale, Michela Brambatti, Paul Hansen, Julia McCain, Jessica Lin, Barry Greenberg; University of California, San Diego, San Diego, CA
159 Takotsubo Cardiomyopathy in HFrEF and Thrombocytopenia: Multi-Center Machine Learning Supported Analysis of Mortality and Costs among 6+ Million Hospitalizations Phi Tran1, Dominique Monlezun2, Sovik De Sirkar2, Gloria Iliescu1, Peter Kim1, Juan Lopez-Mattei1, Jean-Bernard Durand1, Nicolas Palaskas1, Cezar Iliescu1; 1The University of Texas MD Anderson Cancer Center, Houston, TX; 2The University of Texas Health Science Center at Houston, Houston, TX Introduction: Distinguishing Takotsubo Cardiomyopathy (TTC) from ischemic heart disease in patients presenting with acute on chronic heart failure is particularly challenging in patients with thrombocytopenia due to the need for coronary angiography. This is the first known nationally representative study on TTC predictors and its relation to mortality and total costs in HFrEF and thrombocytopenic patient admissions. Methods: The 2016 data from the nation’s top all-payer hospitalization dataset (the National Inpatient Sample) was used for backward propagation neural network machine learning augmenting multivariable regression fully adjusting for age, race, income, primary malignancy, metastases, and mortality risk among chronic thrombocytopenia (platelets <150,000) and HFrEF (EF <50%) inpatient admissions. Results: Among 6,039,969 inpatient admissions, TTC compared to non-TTC patients were more likely to have HFrEF (8.27% versus 2.84%, p<0.001) but had comparable proportion of thrombocytopenia (7.55% versus 7.19%, p=0.603). In multivariable regression, thrombocytopenia significantly increased mortality (OR 1.22, p<0.001) unlike TTC and HFrEF. The top predictor of TTC was HFrEF (OR 2.54, p<0.001), followed by Caucasian race (OR 1.85, p<0.001), the highest median income quartile (OR 1.33, p<0.001), and thrombocytopenia (OR 1.13, p=0.015). Among HFrEF, PCI significantly reduced inpatient mortality (0.63, p<0.001) but not specifically for TTC (1.02, p=0.970), though it did significantly reduce total costs for TTC patients (-$57,730.72, p<0.001). In thrombocytopenia, PCI similarly did not have a significant mortality impact on TTC (OR 0.72, p=0.357) but it did significantly decrease total costs when done in TTC patients (-$102,730.50, p<0.001). Conclusions: This study provides the first large multi-center robust analysis suggesting HFrEF, thrombocytopenia, and sociodemographics as TTC predictors. It is possible patients with thrombocytopenia and HFrEF are more likely to be labeled as TTC rather than have invasive testing to rule out ischemic heart disease. The subset of patient admissions in which TTC
Background: Patients hospitalized with acute heart failure (AHF) are at increased risk for clinical events during the 30-day period following discharge. The 2013 ACC/AHA heart failure (HF) guidelines recommend that such patients should be “transitioned to oral diuretic therapy to verify its effectiveness.” Although evidence that this strategy is effective is limited, many institutions transition patients from intravenous to oral diuretic therapy for at least 24 hours based on the premise that it improves outcomes. We investigated the effectiveness of this strategy on postdischarge outcomes in patients hospitalized for AHF at our institution. Methods: In a retrospective chart review study, we evaluated all patients with a primary diagnosis of HF, regardless of left ventricular ejection fraction (LVEF), who were hospitalized from 8/1/2016 - 7/31/2017, discharged on an oral diuretic and followed at our institution. Baseline characteristics of patients who were discharged with at least a 24-hour period on oral diuretics and those who were discharged with less than 24 hours of observation on oral diuretics were compared and the effect of these strategies on a composite of all-cause mortality and all-cause rehospitalization, HF rehospitalization and all-cause rehospitalization were assessed. Results: Of the 285 consecutive patients who met study entry criteria, 178 were observed for at least 24 hours on oral diuretics prior to discharge and 104 were not. These groups were similar in baseline characteristics including age, gender, co-morbidities, baseline blood chemistries, hemoglobin, BNPP, HF etiology, LVEF and factors triggering HF exacerbation. The group that was observed for 24 hours or more on oral diuretics had longer hospital stays and experienced greater weight and net volume loss than patients observed on oral diuretics for less than 24 hours. The latter group was more likely to have had changes made in their dose of neurohormonal blocking agents and diuretics within the 24-hour period prior to discharge. In contrast to expectations, all-cause mortality or all-cause hospitalization (27.5% vs 15%; p=0.019), all-cause rehospitalization (27% vs 14%; p=0.009) and AHF rehospitalization (12.9% vs 6.5%; p=0.064) occurred more commonly in patients who were observed for 24 hours on oral diuretics than for patients who were not. Conclusion: In a population of patients discharged from an academic medical center after an episode of AHF, the strategy of transitioning patients to oral diuretics for at least 24 hours prior to discharge failed to improve 30-day outcomes. While this study has limitations due to the relatively small patient population followed at a single center, the results do not support the recommendation to observe patients on oral diuretics for at least 24 hours prior to discharge and they raise the question of whether providers should be encouraged to follow this practice without prospective studies demonstrating its effectiveness.
161 Potential Markers of Sacubitril-Valsartan Tolerance Gabrielle L. Ramirez, Todd Nicklas, Matthew Fink, Kenneth Margulies; University of Pennsylvania, Philadelphia, PA Introduction: Sacubitril-Valsartan (S-V), or Entresto, is a combined angiotensin receptor-neprilysin inhibitor used to treat chronic heart failure. Some patients have shown remarkable improvements while on the drug and others were unable to tolerate the drug. Our objective was to determine markers of tolerance to S-V in heart failure patients outside the clinical trial setting. Methods and Results: This retrospective study analyzed data collected at baseline and within a year after initiation of treatment at our referral-based, academic medical practice. Exclusion criteria were patients who discontinued S-V therapy due to inability to pay and patients with a prior history of angioedema. Eighty patients (63 § 12 years; 69% men; 69% white) were included. Of these subjects, 45 were ultimately intolerant vs. 35 tolerant. Seven intolerant patients (16%) were deceased at the time of screening, and none of the tolerant patients were deceased. The majority of intolerant patients (58%, n=26) discontinued treatment within the first 30 days and nearly a quarter (24%) stopped treatment within 7 days. Tolerant and intolerant populations had comparable risk factors and baseline values. At one week after initiation of therapy, intolerant patients had lower systolic blood pressure (p=0.010) compared with ultimately tolerant patients (Figure). Though intolerant patients had a lower creatinine (p=0.020) at one week after initiation of S-V, they experienced a significant increase soon afterward. Of the tolerant patients, 6% (n=2) had their dose reduced and 54% (n=19) were successfully up-titrated from the starting dose. Conclusions: Significant decreases in systolic blood pressure at week 1 seem to identify individuals who may experience a sharp early worsening of renal function and will not ultimately tolerate S-V. Patients’ blood pressure and renal function
155 Influence of a Novel Multidisciplinary Cognitive Impairment Intervention on Post-Acute Care in an Inpatient Community-Based HFrEF Cohort Vijay U. Rao1, Atul R. Chugh1, Kathy Stark1, Donna McClory1, Eiran Z. Gorodeski2; 1 Franciscan Health, Indiana Heart Physicians, Indianapolis, IN; 2Cleveland Clinic, Cleveland, OH Background: Cognitive impairment (CI) is a strong predictor of six-month mortality and risk for re-admission in older hospitalized heart failure (HF) patients. We sought to develop a novel, multidisciplinary CI inpatient intervention to improve post-acute care discharge planning and reduce 30-day hospital re-admissions. Methods: From July 2016 to July 2018 at a large, community-based hospital, we developed a CI inpatient screening program using the Mini-Cog test for eligible patients over the age of 65 admitted with a primary diagnosis of HF. The Mini-Cog is a three word recall and clock drawing test, scored between 0 and 5 points. A score of 2 or below identifies CI. In May 2017, Mini-Cog (+) patients received a multidisciplinary CI intervention led by palliative care nurses and speech therapists which included: a) family meeting b) goals of care discussion c) family-directed HF education and d) speech therapy evaluation. We compared the pre-intervention cohort (10 months prior to intervention) with the post-intervention cohort (15 months after intervention) with respect to discharge disposition and 30-day re-admission rates. Results: We screened 740 patients for CI, of which 11.4% were Mini-Cog (+). In Mini-Cog (+) patients, the CI intervention increased the percentage of home health discharges (46% vs 20%, p=0.02, OR 3.4) and decreased the percentage of home discharges (44% vs 15%, p=0.008, OR 0.23), while rates of skilled nursing and hospice discharges were not significantly different (29% vs 26%, p=0.93 and 7% vs 8%, p=1.0), respectively). In the Mini-Cog (-) patients, there were no significant differences in pre vs post intervention cohort discharge disposition. In the combined pre and post intervention cohorts, a greater percentage of Mini-cog (+) patients were discharged to skilled nursing facilities and hospice compared to Mini-cog (-) patients (36.9% vs 19.8%, P < 0.001). While the Mini-Cog (-) patient 30-day re-admission rate in the pre and post intervention cohorts were similar (18% vs 17%), the Mini-cog (+) patient 30-day readmission rate was numerically lower in the post-intervention cohort compared to the pre-intervention cohort (15.3% vs 20.0%, P=0.29). Conclusions: CI represents an important marker of HF post-acute care morbidity and mortality. Our CI multi-disciplinary intervention had a significant impact on discharge disposition with increased utilization of home health services. While not achieving statistical significance likely due to inadequate power, our intervention numerically lowered rates of 30-day re-admissions in a high-risk CI impaired population. Moreover, re-admission rates were similar to those noted in the Mini-Cog (-) group in this high-risk population. Hence, we believe these data justify further validation of this novel, multi-disciplinary approach in a larger multi-center study.
initial symptoms included cardiac (n=40, 59%), peripheral or autonomic neuropathy (n=16, 24%), and carpal tunnel syndrome (n=5, 7%). Cardiac was predominantly the initial symptom experienced by patients with wild type ATTR amyloidosis (75%) while cardiac (48%) or neuropathy (38%) were the initial symptoms experienced most often by patients with hereditary ATTR amyloidosis. Only one-quarter (n=17) of patients received their diagnosis within 6 months of their initial symptom onset (mean=3.6 years), and 5 (7%) patients were identified through genetic testing before symptom onset. Twenty-two (32%) patients reported seeing 6 or more HCPs before receiving their ATTR amyloidosis diagnosis; more than two-thirds (n=47, 69%) of the sample reported seeing 3 or more HCPs before diagnosis. Patients commonly visited primary care providers (n=52) and cardiologists (n=51) with a median of 3 visits to primary care providers and 2 visits to cardiologists before receiving their diagnosis; however, cardiologists most often made or confirmed final diagnoses of ATTR amyloidosis (n=49, 72%). Of the reported diagnostic procedures, the most common were echocardiogram (n=50), biopsy (n=45), MRI or CMR (n=34), genetic testing (n=30), cardiac biomarkers (n=18); and radionuclide imaging (PYP/DPD; n=13); among biopsy locations, cardiac (n=29) and fat pad (n=22) biopsies were the most frequently reported. Conclusions: These results indicate that the journey to a diagnosis for patients with ATTR-CM is complicated and delays in diagnosis are common. Increased awareness of ATTR amyloidosis among cardiologists may help to raise early suspicion, reduce the time to an accurate diagnosis, and initiate early treatment.
157 Takotsubo Cardiomyopathy Mortality and Costs in Cancer, PCI, and Racial Disparities: Propensity Score Adjusted Machine Learning Guided Analysis of 6+ Million Inpatient Admissions Phi Tran1, Dominique Monlezun2, Sovik De Sirkar2, Gloria Iliescu1, Peter Kim1, Juan Lopez-Mattei1, Jean-Bernard Durand1, Nicolas Palaskas1, Cezar Iliescu1; 1The University of Texas MD Anderson Cancer Center, Houston, TX; 2The University of Texas Health Science Center at Houston, Houston, TX Introduction: Takotsubo Cardiomyopathy (TTC) remains an elusive diagnosis complicating prompt and appropriate care for patients presenting to the hospital with heart failure symptoms. This study demonstrates the first multi-center analysis of TTC and percutaneous coronary intervention (PCI) mortality, costs, and disparities. Methods: The backward propagation neural network supervised machine learning algorithm supported multivariable regression and propensity score matched analysis of mortality and total hospital costs for TTC in this case-control study of the 2016 National Inpatient Sample (NIS). Results: Of the 6,039,969 hospitalizations, 0.13% were diagnosed with TTC, 132,222 (2.19%) died inpatient, and the median total costs were $29,143 (range $15,587-56,287). In multivariable regression fully adjusting for age, race, and mortality risk, PCI for TTC patients significantly reduced mortality (OR 0.53, p<0.001) and costs (-$62,232.82, p<0.001). In propensity score matched analysis in TTC patients, PCI significantly reduced mortality by 7.30% (p<0.001). Among TTC patients, there were significant income disparities in mortality (versus 1st quartile median income: 2nd [OR1.72, p=0.001], 3rd [OR 1.58, p=0.005], and 4th [OR 1.52, p=0.012]). Conclusions: This is the first known nationally-representative machine learning and propensity score-augmented analysis demonstrating that PCI significantly reduces mortality and inpatient costs for TTC. Since TTC by definition should not have obstructive coronary artery disease to explain the wall motion abnormalities, our findings suggest TTC is misdiagnosed in many inpatient hospitalizations. This helps explain the improvement in mortality that is likely revascularization of ischemic heart disease that caused heart failure with reduced ejection fraction. In addition, this analysis showed that TTC itself has significant mortality disparities based on income.
158 156 Characterizing the Journey to Diagnosis for Patients with Transthyretin Amyloidosis and Accompanying Congestive Heart Failure Asia Sikora Kessler1, Aaron Yarlas1, Michael Pollock2, Spencer Guthrie3, Kristen L. McCausland1; 1Optum, Johnston, RI; 2Akcea Therapeutics, Carlsbad, CA; 3Biopharma Strategic Consulting, LLC, San Francisco, CA Introduction: Transthyretin (ATTR) amyloidosis is a rare, systemic, progressive, and fatal condition in which misfolded transthyretin proteins deposit as amyloid in nervous, cardiac, and other tissue. The deposition of amyloid in cardiac tissue results in cardiomyopathy (CM). Hypothesis: The journey to diagnosis for patients with ATTR amyloidosis and accompanying CM (ATTR-CM) is long and complex and may result in delayed treatment initiation due to misdiagnosis. Methods: Adult patients in the US and Canada with ATTR amyloidosis were enrolled in an online, longitudinal observational survey study. Analyses were based on initial survey responses from a subset of patients with self-reported cardiac involvement (n=68). Journey to diagnosis was assessed in terms of: age at symptom onset, types of initial symptoms, time to diagnosis, number and types of healthcare providers (HCPs) consulted, frequency of visits to HCPs prior to diagnosis, types of HCPs who provided diagnosis, and types of diagnostic procedures performed by HCPs while seeking a diagnosis. Results were summarized descriptively. Results and Conclusions: On average, patients were 60.9 years of age at the time of symptom onset. Self-reported
The Impact of an Advance Care Planning Intervention for Patients with Heart Failure Therese C. Prentice1, Robin Lawson2; 1Abington Hospital Jefferson Health, Abington, PA; 2University of Alabama, Tuscaloosa, AL Introduction: Patients with chronic heart failure face a life-limiting disease trajectory, yet many have not addressed end-of-life planning. The ideal method to assist patients with advance directive (AD) completion and end-of-life goal setting is not clearly established. Hypothesis: A nurse practitioner led, interactive education program for patients hospitalized with acute decompensated heart failure utilizing the Institute of Healthcare Improvement tool, The Conversation Project, will improve patient attitudes regarding advance directives, increase completion of advance directive documents and increase discussion of end-of-life goals with significant others and health care providers. Methods: A convenience sample of 30 patients hospitalized with acute decompensated heart failure who had not completed AD was used. Study participants completed the Advance Directive Attitude Survey (ADAS) prior to reviewing The Conversation Project materials and receiving education from a nurse practitioner trained in end-of-life counseling. A comparison of pre-/post-intervention outcome measures included ADAS scores, completion of AD, establishment of surrogate decision maker and discussion of end-of-life goals with provider and significant others. Results: All study participants (n=30) had positive ADAS scores prior to the intervention. Post intervention outcomes were measured 30 days after the intervention in 25 participants (83%). ADAS scores remained positive with no
The 23rd Annual Scientific Meeting HFSA significant change (p=0.53). A noteworthy 64% (n=16) of participants discussed AD with significant other, 40% (n=10) established surrogate decision maker and 28% (n=7) completed AD. Only 12% (n=3) discussed AD with a health care provider. Conclusions: A nurse practitioner led advance care planning program using The Conversation Project showed clinically significant, but limited outcome improvement. A positive attitude regarding AD was not associated with completion of AD documents or discussion of end-of-life goals with significant others or health care providers. Further study of measures to improve the AD completion process, including programs targeting the outpatient population over a longer time frame and strategies to increase discussion with health care providers is recommended.
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patients also received PCI resulting in improved mortality and total costs suggests that ischemic heart disease rather than TTC was the culprit. In addition, the thrombocytopenic patients with acute on chronic heart failure that received PCI and were labeled as TTC also had decreased total costs. This study may help provide cardiologists clinically relevant predictors of TTC and its outcomes to risk stratify patients. In addition, it suggests that despite thrombocytopenia providers should not be quick to label patients with TTC but rather consider invasive workup with possible PCI that may decrease costs of inpatient admissions.
160 Transitioning Patients to Oral Diuretics 24 Hours before Discharge from Heart Failure Hospitalization Does Not Improve 30 Day Outcomes Stephen Schale, Michela Brambatti, Paul Hansen, Julia McCain, Jessica Lin, Barry Greenberg; University of California, San Diego, San Diego, CA
159 Takotsubo Cardiomyopathy in HFrEF and Thrombocytopenia: Multi-Center Machine Learning Supported Analysis of Mortality and Costs among 6+ Million Hospitalizations Phi Tran1, Dominique Monlezun2, Sovik De Sirkar2, Gloria Iliescu1, Peter Kim1, Juan Lopez-Mattei1, Jean-Bernard Durand1, Nicolas Palaskas1, Cezar Iliescu1; 1The University of Texas MD Anderson Cancer Center, Houston, TX; 2The University of Texas Health Science Center at Houston, Houston, TX Introduction: Distinguishing Takotsubo Cardiomyopathy (TTC) from ischemic heart disease in patients presenting with acute on chronic heart failure is particularly challenging in patients with thrombocytopenia due to the need for coronary angiography. This is the first known nationally representative study on TTC predictors and its relation to mortality and total costs in HFrEF and thrombocytopenic patient admissions. Methods: The 2016 data from the nation’s top all-payer hospitalization dataset (the National Inpatient Sample) was used for backward propagation neural network machine learning augmenting multivariable regression fully adjusting for age, race, income, primary malignancy, metastases, and mortality risk among chronic thrombocytopenia (platelets <150,000) and HFrEF (EF <50%) inpatient admissions. Results: Among 6,039,969 inpatient admissions, TTC compared to non-TTC patients were more likely to have HFrEF (8.27% versus 2.84%, p<0.001) but had comparable proportion of thrombocytopenia (7.55% versus 7.19%, p=0.603). In multivariable regression, thrombocytopenia significantly increased mortality (OR 1.22, p<0.001) unlike TTC and HFrEF. The top predictor of TTC was HFrEF (OR 2.54, p<0.001), followed by Caucasian race (OR 1.85, p<0.001), the highest median income quartile (OR 1.33, p<0.001), and thrombocytopenia (OR 1.13, p=0.015). Among HFrEF, PCI significantly reduced inpatient mortality (0.63, p<0.001) but not specifically for TTC (1.02, p=0.970), though it did significantly reduce total costs for TTC patients (-$57,730.72, p<0.001). In thrombocytopenia, PCI similarly did not have a significant mortality impact on TTC (OR 0.72, p=0.357) but it did significantly decrease total costs when done in TTC patients (-$102,730.50, p<0.001). Conclusions: This study provides the first large multi-center robust analysis suggesting HFrEF, thrombocytopenia, and sociodemographics as TTC predictors. It is possible patients with thrombocytopenia and HFrEF are more likely to be labeled as TTC rather than have invasive testing to rule out ischemic heart disease. The subset of patient admissions in which TTC
Background: Patients hospitalized with acute heart failure (AHF) are at increased risk for clinical events during the 30-day period following discharge. The 2013 ACC/AHA heart failure (HF) guidelines recommend that such patients should be “transitioned to oral diuretic therapy to verify its effectiveness.” Although evidence that this strategy is effective is limited, many institutions transition patients from intravenous to oral diuretic therapy for at least 24 hours based on the premise that it improves outcomes. We investigated the effectiveness of this strategy on postdischarge outcomes in patients hospitalized for AHF at our institution. Methods: In a retrospective chart review study, we evaluated all patients with a primary diagnosis of HF, regardless of left ventricular ejection fraction (LVEF), who were hospitalized from 8/1/2016 - 7/31/2017, discharged on an oral diuretic and followed at our institution. Baseline characteristics of patients who were discharged with at least a 24-hour period on oral diuretics and those who were discharged with less than 24 hours of observation on oral diuretics were compared and the effect of these strategies on a composite of all-cause mortality and all-cause rehospitalization, HF rehospitalization and all-cause rehospitalization were assessed. Results: Of the 285 consecutive patients who met study entry criteria, 178 were observed for at least 24 hours on oral diuretics prior to discharge and 104 were not. These groups were similar in baseline characteristics including age, gender, co-morbidities, baseline blood chemistries, hemoglobin, BNPP, HF etiology, LVEF and factors triggering HF exacerbation. The group that was observed for 24 hours or more on oral diuretics had longer hospital stays and experienced greater weight and net volume loss than patients observed on oral diuretics for less than 24 hours. The latter group was more likely to have had changes made in their dose of neurohormonal blocking agents and diuretics within the 24-hour period prior to discharge. In contrast to expectations, all-cause mortality or all-cause hospitalization (27.5% vs 15%; p=0.019), all-cause rehospitalization (27% vs 14%; p=0.009) and AHF rehospitalization (12.9% vs 6.5%; p=0.064) occurred more commonly in patients who were observed for 24 hours on oral diuretics than for patients who were not. Conclusion: In a population of patients discharged from an academic medical center after an episode of AHF, the strategy of transitioning patients to oral diuretics for at least 24 hours prior to discharge failed to improve 30-day outcomes. While this study has limitations due to the relatively small patient population followed at a single center, the results do not support the recommendation to observe patients on oral diuretics for at least 24 hours prior to discharge and they raise the question of whether providers should be encouraged to follow this practice without prospective studies demonstrating its effectiveness.
161 Potential Markers of Sacubitril-Valsartan Tolerance Gabrielle L. Ramirez, Todd Nicklas, Matthew Fink, Kenneth Margulies; University of Pennsylvania, Philadelphia, PA Introduction: Sacubitril-Valsartan (S-V), or Entresto, is a combined angiotensin receptor-neprilysin inhibitor used to treat chronic heart failure. Some patients have shown remarkable improvements while on the drug and others were unable to tolerate the drug. Our objective was to determine markers of tolerance to S-V in heart failure patients outside the clinical trial setting. Methods and Results: This retrospective study analyzed data collected at baseline and within a year after initiation of treatment at our referral-based, academic medical practice. Exclusion criteria were patients who discontinued S-V therapy due to inability to pay and patients with a prior history of angioedema. Eighty patients (63 § 12 years; 69% men; 69% white) were included. Of these subjects, 45 were ultimately intolerant vs. 35 tolerant. Seven intolerant patients (16%) were deceased at the time of screening, and none of the tolerant patients were deceased. The majority of intolerant patients (58%, n=26) discontinued treatment within the first 30 days and nearly a quarter (24%) stopped treatment within 7 days. Tolerant and intolerant populations had comparable risk factors and baseline values. At one week after initiation of therapy, intolerant patients had lower systolic blood pressure (p=0.010) compared with ultimately tolerant patients (Figure). Though intolerant patients had a lower creatinine (p=0.020) at one week after initiation of S-V, they experienced a significant increase soon afterward. Of the tolerant patients, 6% (n=2) had their dose reduced and 54% (n=19) were successfully up-titrated from the starting dose. Conclusions: Significant decreases in systolic blood pressure at week 1 seem to identify individuals who may experience a sharp early worsening of renal function and will not ultimately tolerate S-V. Patients’ blood pressure and renal function