Daniel Dooley

Lack of evidence of lower 30-day all-cause readmission in Medicare beneficiaries with heart failure and reduced ejection fraction discharged on spironolactone ☆

BACKGROUND Therapy with evidence-based heart failure (HF) medications has been shown to be associated with lower risk of 30-day all-cause readmission in patients with HF and reduced ejection fraction (HFrEF). METHODS We examined the association of aldosterone antagonist use with 30-day all-cause readmission in this population. Of the 2443 Medicare beneficiaries with HF and left ventricular EF ≤35% discharged home from 106 Alabama hospitals during 1998-2001, 2060 were eligible for spironolactone therapy (serum creatinine ≤2.5 for men and ≤2mg/dl for women, and serum potassium <5mEq/L). After excluding 186 patients already receiving spironolactone on admission, the inception cohort consisted of 1874 patients eligible for a new discharge prescription for spironolactone, of which 329 received one. Using propensity scores for initiation of spironolactone therapy, we assembled a matched cohort of 324 pairs of patients receiving and not receiving spironolactone balanced on 34 baseline characteristics (mean age 72years, 42% women, 33% African American). RESULTS Thirty-day all-cause readmission occurred in 17% and 19% of matched patients receiving and not receiving spironolactone, respectively (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.64-1.32; p=0.650). Spironolactone had no association with 30-day all-cause mortality (HR, 0.84; 95% CI, 0.38-1.88; p=0.678) or HF readmission (HR, 0.74; 95% CI, 0.41 1.31; p=0.301). These associations remained unchanged during 12months of post-discharge follow-up. CONCLUSION A discharge prescription for spironolactone had no association with 30-day all-cause readmission among older, hospitalized Medicare beneficiaries with HFrEF eligible for spironolactone therapy.

Similar Clinical Benefits from Below-Target and Target Dose Enalapril in Patients with Heart Failure in the SOLVD Treatment Trial.

To examine associations of below‐target and target dose of enalapril, an angiotensin‐converting enzyme (ACE) inhibitor, with outcomes in patients with heart failure and reduced ejection fraction (HFrEF) in the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial.

Systolic–diastolic hypertension versus isolated systolic hypertension and incident heart failure in older adults: Insights from the Cardiovascular Health Study

BACKGROUND Isolated systolic hypertension (ISH) is common in older adults and is a risk factor for incident heart failure (HF). We examined the association of systolic-diastolic hypertension (SDH) with incident HF and other outcomes in older adults. METHODS In the Cardiovascular Health Study (CHS), 5776 community-dwelling adults≥65years had data on baseline systolic and diastolic blood pressure (SBP and DBP). We excluded those with DBP<60mmHg (n=821), DBP≥90 and SBP<140mmHg (n=28), normal BP, taking anti-hypertensive drugs (n=1138), normal BP, not taking anti-hypertensive drugs, history of hypertension (n=193), and baseline HF (n=101). Of the remaining 3495, 1838 had ISH (SBP≥140 and DBP<90mmHg) and 240 had SDH (SBP≥140 and DBP≥90mmHg). The main outcome was centrally-adjudicated incident HF over 13years of follow-up. RESULTS Participants had a mean (±SD) age of 73 (±6)years, 57% were women, and 16% African American. Incident HF occurred in 25%, 22% and 11% of participants with ISH, SDH and no hypertension, respectively. Compared to no hypertension, multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI) for incident HF associated with ISH and SDH were 1.86 (1.51-2.30) and 1.73 (1.23-2.42), respectively. Cardiovascular mortality occurred in 22%, 24% and 9% of those with ISH, SDH and no hypertension, respectively with respective multivariable-adjusted HRs (95% CIs) of 1.88 (1.49-2.37) and 2.30 (1.64-3.24). CONCLUSION Among older adults with hypertension, both SDH and ISH have similar associations with incident HF and cardiovascular mortality.

Digoxin use and lower risk of 30-day all-cause readmission in older patients with heart failure and reduced ejection fraction receiving β-blockers.

Digoxin use has been associated with a lower risk of 30‐day all‐cause admission and readmission in patients with heart failure and reduced ejection fraction (HFrEF).

HEART FAILURE HOSPITALIZATION (HFH) DESPITE DIGOXIN THERAPY VERSUS NO HFH DESPITE PLACEBO IN THE DIGITALIS INVESTIGATION GROUP (DIG) TRIAL: INSIGHTS INTO RISK FACTORS FOR HFH IN HF AND REDUCED EJECTION FRACTION (HFREF)

Background: In the DIG trial, 6800 patients with HFrEF (EF≤45%) were randomized to receive either placebo (n=3403) or digoxin (n=3397) and followed for a mean of 37 months. Digoxin significantly reduced the risk of HFH by 28% (HR, 0.72; 95% CI, 0.66–0.79). However, 27% of patients in the digoxin

ORTHOPNEA OR PAROXYSMAL NOCTURNAL DYSPNEA IN OLDER ADULTS WITHOUT PREVALENT HEART FAILURE IS A PREDICTOR, BUT NOT AN INDEPENDENT RISK FACTOR FOR INCIDENT HEART FAILURE: INSIGHTS FROM THE CARDIOVASCULAR HEALTH STUDY

Background: Among older adults, <20% of those with either orthopnea or PND have definite heart failure (HF), which limits their usefulness in the diagnosis of prevalent HF in the community (PMID: 19576357). However, their usefulness in predicting incident HF remains unclear. Methods: In the

ADVERSE OUTCOMES WITH USE OF HYDRALAZINE AND NITRATE COMBINATION THERAPY IN HOSPITALIZED OLDER NON-BLACK PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION (HFREF)

Background: A combination of hydralazine and isosorbide dinitrate is recommended to self-described African American patients with HFrEF receiving optimal therapy with ACE inhibitors and beta-blockers, unless contraindicated. We examined the association of the use of both hydralazine and nitrates

The Role of Positive Inotropic Drugs in the Treatment of Older Adults with Heart Failure and Reduced Ejection Fraction

Positive inotropic drugs have long been studied for their potential benefits in patients with heart failure and reduced ejection fraction (HFrEF). Although there has been an extensive amount of research about the clinical effects of these drugs in general, few studies examined their effect in older patients. Therefore, there is little or no evidence to guide the use of positive inotropes in older patients with HFrEF. However, recommendations from national heart failure guidelines may be generalized to older HFrEF patients on an individual basis, taking into consideration the basic geriatric principles of pharmacotherapy: start low and go slow.

Operator volumes and salvage index in AMI

Background Cardiac MR (CMR) is a useful diagnostic tool for the evaluation of myocardial infarction. While several previous studies have assessed the effect of operator volumes on outcome following coronary angioplasty, none have utilized salvage index measured by CMR as a primary endpoint. Prior studies relying on major adverse cardiac events as endpoints required very large sample sizes for sufficient power. The prognostic ability of CMR can, in theory, reduce the minimum necessary sample size, as recent research has provided evidence of CMR as a reliable, reproducible method for determining infarct size and AAR and salvage index via T2-weighted imaging.