Title: Heart Failure With Preserved Ejection Fraction in Outpatients With Unexplained Dyspnea: A Pressure-Volume Loop Analysis
Topic: Heart Failure/Transplant
Date Posted: 5/4/2010
Author(s): Penicka M, Bartunek J, Trakalova H, et al.
Citation: J Am Coll Cardiol 2010;55:1701-1710.
Clinical Trial: No
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JACC Article: Heart Failure With Preserved Ejection Fraction in Outpatients With Unexplained Dyspnea: A Pressure-Volume Loop Analysis
Study Question: Is heart failure with preserved ejection fraction (HFPEF) present in outpatients with unexplained chronic dyspnea, and does it elucidate its underlying mechanisms in this population, using invasive pressure-volume loop analysis?
Methods: The study cohort, comprised of 30 patients (ages 67 ± 8.6 years, 27% males) with preserved left ventricular (LV) EF (≥50%) and unexplained chronic New York Heart Association functional class II-III dyspnea, underwent heart catheterization. Patients with significant coronary artery stenosis (≥50%) were excluded. Pressure-volume loops were assessed using a conductance catheter at rest, hand-grip exercise, leg lifting, and nitroprusside and dobutamine infusion.
Results: Sixty-six percent (n = 20) of patients showed LV end-diastolic pressure >16 mm Hg (normal LV systolic function), whereas the remaining 10 patients served as controls. Patients with HFPEF had significantly higher end-diastolic stiffness (0.205 ± 0.074 vs. 0.102 ± 0.017, p < 0.001) at rest, and their end-diastolic pressure-volume relationship showed a consistent upward and leftward shift during all hemodynamic interventions compared with controls. Regarding the underlying mechanism of HFPEF, 70% (n = 14) of patients had markedly increased end-diastolic stiffness, which was considered a sufficient single pathology to induce increased LV end-diastolic pressure. Twenty percent (n = 4) of patients showed a concomitant presence of moderately increased stiffness and severe LV dyssynchrony, and the remaining 10% (n = 2) of patients, with normal stiffness, showed significant exercise-induced mitral regurgitation at hand-grip exercise. According to the study investigators, if the invasive pressure measurements were absent, only 25% (n = 5) of the outpatients with HFPEF fulfilled the European Society of Cardiology definition of HFPEF.
Conclusions: The authors concluded that a significant proportion of stable outpatients with unexplained chronic dyspnea may have HFPEF. In this cohort, increased LV stiffness, dyssynchrony, and dynamic mitral regurgitation were the major mechanisms underlying development of HFPEF.
Perspective: This is an important study because it suggests that patients with unexplained dyspnea may benefit from a right heart catheterization to determine the pulmonary capillary wedge pressure (as a surrogate for LV end-diastolic pressure) to make a diagnosis of HF. It has always been argued that HF is a ‘clinical’ diagnosis, but as technology evolves, we may continue to detect new HF patients that were hitherto undetected. Ragavendra R. Baliga, M.B.B.S.
Title: Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure
Topic: Heart Failure/Transplant
Date Posted: 5/4/2010 4:00:00 PM
Author(s): Hernandez AF, Greinger MA, Fonarow GC, et al.
Citation: JAMA 2010;303:1716-1722.
Clinical Trial: No
Study Question: What is the association between outpatient follow-up within 7 days after discharge from a heart failure (HF) hospitalization and readmission within 30 days?
Methods: The study cohort consisted of 30,136 patients from 225 hospitals. The study was an observational analysis of patients ages ≥65 years with HF and discharged to home from hospitals participating in the HF quality improvement program from January 1, 2003, through December 31, 2006. The main outcome measure was all-cause readmission within 30 days after discharge.
Results: Median length of stay was 4 days (interquartile range, 2-6) and 21.3% of patients were readmitted within 30 days. At the hospital level, the median percentage of patients who had early follow-up after discharge from the index hospitalization was 38.3% (interquartile range, 32.4-44.5%). Compared with patients whose index admission was in a hospital in the lowest quartile of early follow-up (30-day readmission rate, 23.3%), the rates of 30-day readmission were 20.5% among patients in the second quartile (risk adjusted hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.93), 20.5% among patients in the third quartile (risk-adjusted HR, 0.87; 95% CI, 0.78-0.96), and 20.9% among patients in the fourth quartile (risk-adjusted HR, 0.91; 95% CI, 0.83-1.00).
Conclusions: The authors concluded that patients who are discharged from hospitals that have higher early follow-up rates have a lower risk of 30-day readmission.
Perspective: From Ragavendra R. Baliga, M.B.B.S.: This is an important study because it confirms what HF physicians have always known about the importance of timely follow-up of patients after discharge from an index HF hospitalization. The data from this study are particularly helpful to hospitals trying to put together a strategy to reduce re-admission rates for hospitalizations. It has been argued that all HF patients who are admitted to a hospital be managed by a Heart Failure Response Team whose responsibilities include ensuring that patients are scheduled for early follow-up (Heart Fail Clin 2009;5:xi-xiv). It would be interesting to know whether early and regular follow-up of HF patients eventually also results not only in reduced hospitalizations, but also in improved long-term survival.
Expert Commentary From Alfred A. Bove, M.D.: Until now, early follow-up for HF patients after discharge had face validity only. This study confirms the importance of establishing coordinated systems of care in which patients are evaluated early after discharge.
The American College of Cardiology's national quality improvement initiative, Hospital to Home (H2H), identifies early follow-up as one of three core concepts for reducing hospital readmissions. Discharged patients should have a follow-up visit scheduled within 1 week of discharge, as well as the means of getting to that appointment.
Providing support during the transition from inpatient to outpatient status is essential. Hospitals participating in the H2H initiative have increased scheduled appointments by having office practices block appointment slots for discharged patients and by having prepurchased time available.