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Weintraub et al

Acute Heart Failure Syndromes


tides, and AHFS as the primary cause for admission.9,34,63,125 An elevated cardiac troponin level has also been associated with nearly a 3-fold higher in-hospital mortality.126 Several comor- bidities have been identified with increased in-hospital mortality. These include liver disease, previous cerebrovascular events, peripheral vascular disease, and chronic obstructive lung disease. Factors associated with a more favorable prognosis during hospitalization for AHFS include hospital admission related to de novo AHFS and prehospitalization therapy with ACE inhib- itors or -blockers.63

Readiness for Discharge Postdischarge morbidity and mortality in the first 60 to 90 days is significant, with patients who were followed up in OPTIMIZE-HF having a mortality rate of 8.6% and a rehospitalization rate of 29.6%.127 In addition, among Medi- care patients, HF is the most common reason for readmission within 30 days of discharge regardless of what prompted the index hospital episode.95 To minimize postdischarge event rates, a thorough evaluation and consideration of precipitating factors of AHFS is encouraged. Identification of reversible causes, such as coronary artery disease or valvular dysfunc- tion during hospitalization, may shorten hospital lengths of stay and minimize postdischarge morbidity and mortality. However, early, safe objective end points of hospital admis- sions are lacking. Current ADHF guidelines for ED and hospital disposition are based on limited empirical evi- dence.64,110,128,129 This results in a great deal of clinical uncertainty regarding acute treatment and the end points to be achieved to safely discharge patients. The majority of patients are discharged based on the resolution of acute symptoms providing they have not developed high-risk markers such as worsening renal function, hypotension, or elevated troponins.

Beyond the questions of acute management of AHFS, however, lie unequivocal data regarding the benefit of tradi- tional HF medical therapy including ACE inhibitors, angio- tensin receptor antagonists, -blockers, and selective aldoste- rone receptor antagonists. Early initiation of this therapy, before hospital discharge, with appropriate titration, improves symptoms, reduces hospitalizations, and saves lives. Never-

theless, these therapies remain underutilized82

and several

specialist may be beneficial. Such a program should begin with education before discharge. Even 1 hour of nurse educator–delivered AHFS education has been shown to improve clinical outcomes, increase self-care, and reduce costs.132 The optimal design of this follow-up care remains to be defined, but effective programs have included such com- ponents as outpatient clinic visits within days of discharge, nurse follow-up by phone or visit, ongoing management in a formal HF clinic, home telemetry devices to monitor vital signs, weight, and symptoms, and perhaps more sophisticated measures like hemodynamic and rhythm monitoring.133–136

Postdischarge: Ongoing Assessment and Avoiding Readmission Patients with chronic HF remain at significant risk for morbidity and mortality despite the range of therapies cur- rently available. These risks may be underappreciated not only by the patient, but also by the treating physician and, thus, objective methods of risk assessment and prognosis could be useful. Historically, prognostic assessments were principally used to identify optimal timing of cardiac trans- plantation in ambulatory New York Heart Association Class III patients. A number of multivariate prognostic models have been developed to better characterize a patient’s ongoing risk. The Heart Failure Survival Score incorporates peak oxygen consumption, heart rate, mean arterial pressure, presence or absence of coronary disease, interventricular conduction de- fects, serum sodium concentration, and ejection fraction to characterize patients as low, medium, or high risk for 1-year urgent transplant or death without transplant.137 The Seattle Heart Failure Model incorporates multiple variables with an internet-based risk calculator to estimate 1-, 2-, and 3-year mortality based on disease status and medical interven- tions.138 A cardiopulmonary exercise testing score was de- vised that incorporates not only peak VO2 but also VE/VCO2 slope, and resting end-tidal CO2, and oxygen uptake effi- ciency slope in a multivariate model for predicting 1-year mortality, transplantation, left ventricular assist device im- plantation, and rehospitalization for AHFS.139

performance measures currently used to assess medical cen- ters have not been associated with improved clinical out- comes.130 Performance improvement programs can, however, increase utilization of optimal medical management.131

As an episode of AHFS is controlled, guideline-based therapies are initiated and the patient is prepared for dis- charge. A variety of concerns including economic, health, safety, and resource availability exert pressure to keep the length of stay as short as possible with many benchmarks between 3 and 4 days maximum, although the average length of stay was 4 to 5 days in the OPTMIZE-HF Registry.63 There is a balance between timely and efficient healthcare delivery and that which results in premature discharge and early readmission. Patients who remain symptomatic from AHFS are at increased risk for repeated decompensation or other complications, including death soon after discharge.127 Given the high risk of recidivism for AHFS, a planned transition to outpatient status with close follow-up by a HF clinic or

Readmission of a patient with chronic HF represents a deterioration in their clinical status that probably has prognostic significance.140,141It also represents an opportunity to assess changes in the status of their disease process, inciting factors such as arrhythmias and concomitant diseases such as pneumo- nia,76 review of the medical regimen to ensure optimal manage- ment including device therapies, and assessment of patient compliance, social support, and patient reeducation. A variety of precipitating factors must be considered including: pulmonary infections, angina, hypertension, arrhythmias, medication non- adherence, diet nonadherence, and other noncardiac medical problems.142–144 Predictors for repeat hospitalization in an el- derly population include a HF admission within the previous year, diabetes mellitus, and serum creatinine 2.5.127,145 Weight gain following discharge is also predictive of readmission for AHFS.146 Rehospitalization for HF may also suggest inadequate treatment during a previous stay for AHFS.147,148

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