Jeffrey A. Bakal

Trends in heart failure care: has the incident diagnosis of heart failure shifted from the hospital to the emergency department and outpatient clinics?

Studies of heart failure (HF) incidence and prevalence frequently rely on hospitalization to identify patients. Our objective was to describe the incidence, prevalence, or outcomes for HF patients diagnosed in the outpatient or emergency department (ED) setting.

Testosterone Supplementation in Heart Failure: A Meta-Analysis

Background— Low testosterone is an independent predictor of reduced exercise capacity and poor clinical outcomes in patients with heart failure (HF). We sought to determine whether testosterone therapy improves exercise capacity in patients with stable chronic HF. Methods and Results— We searched Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (1980–2010). Eligible studies included randomized controlled trials (RCTs) reporting the effects of testosterone on exercise capacity in patients with HF. Reviewers determined the methodological quality of studies and collected descriptive, quality, and outcome data. Four trials (n=198; men, 84%; mean age, 67 years) were identified that reported the 6-minute walk test (2 RCTs), incremental shuttle walk test (2 RCTs), or peak oxygen consumption (2 RCTs) to assess exercise capacity after up to 52 weeks of treatment. Testosterone therapy was associated with a significant improvement in exercise capacity compared with placebo. The mean increase in the 6-minute walk test, incremental shuttle walk test, and peak oxygen consumption between the testosterone and placebo groups was 54.0 m (95% CI, 43.0–65.0 m), 46.7 m (95% CI, 12.6–80.9 m), and 2.70 mL/kg per min (95% CI, 2.68–2.72 mL/kg per min), respectively. Testosterone therapy was associated with a significant increase in exercise capacity as measured by units of pooled SDs (net effect, 0.52 SD; 95% CI, 0.10–0.94 SD). No significant adverse cardiovascular events were noted. Conclusions— Given the unmet clinical needs, testosterone appears to be a promising therapy to improve functional capacity in patients with HF. Adequately powered RCTs are required to assess the benefits of testosterone in this high-risk population with regard to quality of life, clinical events, and safety.

Heart Failure Is a Risk Factor for Orthopedic Fracture A Population-Based Analysis of 16 294 Patients

Background— Heart failure (HF) is associated with factors that may contribute to accelerated bone loss and subsequent fractures. Whether it leads to an increased fracture risk is unknown. Methods and Results— A population-based cohort of consecutive patients ≥65 years of age with cardiovascular disease presenting to all emergency rooms between 1998 and 2001 in Alberta, Canada (n=16294 patients), was used. The 2041 patients with a new diagnosis of HF were compared with a control group of 14 253 patients with non-HF cardiovascular diagnoses. The primary outcome was any orthopedic fracture requiring hospital admission in the year after the emergency room visit. Patients with HF had a median age of 78 years (interquartile range, 72 to 84 years), and 51.9% were female; control subjects had a median age of 73 years (interquartile range, 68 to 79 years), and 53.2% were female. In the first year after the emergency room visit, 4.6% of the HF cohort (n=93) and 1.0% of patients without HF (n=147) sustained an orthopedic fracture (P<0.001). Hip fractures occurred in 26 HF patients (1.3%) and 18 patients (0.1%) without HF (P<0.001). After multivariable adjustment, HF was independently associated with a greater risk of any orthopedic fracture (adjusted odds ratio, 4.0; 95% CI, 2.9 to 5.3) or hip fracture (adjusted odds ratio, 6.3; 95% CI, 3.4 to 11.8). Conclusions— HF is associated with an increased risk of subsequent orthopedic fracture, particularly hip fracture. This suggests that screening for and treatment of osteoporosis to reduce fracture risk need to be considered in those with HF.

Meta-analysis: Cardiac Resynchronization Therapy for Patients With Less Symptomatic Heart Failure

BACKGROUND Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with advanced symptoms of heart failure. PURPOSE To assess the benefits and harms of CRT in patients with advanced heart failure and those with less symptomatic disease. DATA SOURCES A search of electronic databases (1950 to December 2010), hand-searching of reference lists, and unpublished data from principal investigators. Searches were not limited to the English language. STUDY SELECTION Randomized, controlled trials of CRT compared with usual care and right or left ventricular pacing in adults with heart failure and a left ventricular ejection fraction of 0.40 or less. DATA EXTRACTION Two reviewers performed independent study selection, data abstraction, and quality assessment by using the Cochrane tool for assessing risk for bias. DATA SYNTHESIS There were 9082 patients in 25 trials. In patients with New York Heart Association (NYHA) class I and II symptoms, CRT reduced all-cause mortality (6 trials, 4572 participants; risk ratio [RR], 0.83 [95% CI, 0.72 to 0.96]) and heart failure hospitalizations (4 trials, 4349 participants; RR, 0.71 [CI, 0.57 to 0.87]) without improving functional outcomes or quality of life. In patients with NYHA class III or IV symptoms, CRT improved functional outcomes and reduced both all-cause mortality (19 trials, 4510 participants; RR, 0.78 [CI, 0.67 to 0.91]) and heart failure hospitalizations (11 trials, 2663 participants; RR, 0.65 [CI, 0.50 to 0.86]). The implant success rate was 94.4%; peri-implantation deaths occurred in 0.3% of trial participants, mechanical complications in 3.2%, lead problems in 6.2%, and infections in 1.4%. LIMITATION Subgroup analyses were underpowered and lack data for persons with NYHA class I symptoms, atrial fibrillation, chronic kidney disease, or right bundle branch block. CONCLUSION Cardiac resynchronization therapy is beneficial for patients with reduced left ventricular ejection fraction, symptoms of heart failure, and prolonged QRS, regardless of NYHA class. PRIMARY FUNDING SOURCE None.

Mortality and Readmission of Patients With Heart Failure, Atrial Fibrillation, or Coronary Artery Disease Undergoing Noncardiac Surgery An Analysis of 38 047 Patients

Background— The postoperative risks for patients with coronary artery disease (CAD) undergoing noncardiac surgery are well described. However, the risks of noncardiac surgery in patients with heart failure (HF) and atrial fibrillation (AF) are less well known. The purpose of this study is to compare the postoperative mortality of patients with HF, AF, or CAD undergoing major and minor noncardiac surgery. Methods and Results— Population-based data were used to create 4 cohorts of consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD (n=13 786), or AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September 31, 2006, in Alberta, Canada. The main outcome was 30-day postoperative mortality. The unadjusted 30-day postoperative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (each versus CAD, P<0.0001). Among patients undergoing minor surgical procedures, the 30-day postoperative mortality was 8.5% in NIHF, 8.1% in IHF, 2.3% in CAD, and 5.7% in AF (P<0.0001). After multivariable adjustment, postoperative mortality remained higher in NIHF, IHF, and AF patients than in those with CAD (NIHF versus CAD: odds ratio 2.92; 95% confidence interval 2.44 to 3.48; IHF versus CAD: odds ratio 1.98; 95% confidence interval 1.70 to 2.31; AF versus CAD: odds ratio 1.69; 95% confidence interval 1.34 to 2.14). Conclusions— Although current perioperative risk prediction models place greater emphasis on CAD than HF or AF, patients with HF or AF have a significantly higher risk of postoperative mortality than patients with CAD, and even minor procedures carry a risk higher than previously appreciated.

Risk stratification schemes, anticoagulation use and outcomes: the risk–treatment paradox in patients with newly diagnosed non-valvular atrial fibrillation

Objective To examine whether warfarin use and outcomes differ across CHADS2 and CHA2DS2-VASc risk strata for non-valvular atrial fibrillation (NVAF). Design Population-based cohort study using linked administrative databases in Alberta, Canada. Setting Inpatient and outpatient. Patients 42 834 consecutive patients ≥20 years of age with newly diagnosed NVAF. Main outcome measures Cerebrovascular events and/or mortality in the first year after diagnosis. Results Of 42 834 NVAF patients, 22.7% were low risk on the CHADS2 risk score (0), 27.5% were intermediate risk (1), and 49.8% were high risk (≥2). The CHA2DS2-VASc risk score reclassified 16 722 patients such that 7.8% were defined low risk, 13.8% intermediate risk and 78.4% high risk. Of the elderly cohort (≥65 years) with definite NVAF visits (at least two encounters 30 days apart, n=8780), 49% were taking warfarin within 90 days of diagnosis. Warfarin use did not differ across risk strata using either the CHADS2 (p for trend=0.85) or CHA2DS2-VASC (p=0.35). In multivariable adjusted analyses, warfarin use was associated with substantially lower rates of death or cerebrovascular events for patients with CHADS2 scores of 1 (OR 0.52, 95% CI 0.41 to 0.67) or ≥2 (OR 0.61, 95% CI 0.53 to 0.71), or CHA2DS2-VASc scores of ≥2 (OR 0.60, 95% CI 0.53 to 0.68). Conclusions In elderly patients with NVAF and elevated CHADS2 or CHA2DS2-VASC scores, warfarin users exhibited lower rates of cerebrovascular events and mortality. However, warfarin use did not differ across risk strata, another example of the risk–treatment paradox in cardiovascular disease.

Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure

Background: Early physician follow-up after discharge is associated with lower rates of death and readmission among patients with heart failure. We explored whether physician continuity further influences outcomes after discharge. Methods: We used data from linked administrative databases for all adults aged 20 years or more in the province of Alberta who were discharged alive from hospital between January 1999 and June 2009 with a first-time diagnosis of heart failure. We used Cox proportional hazard models with time-dependent covariates to analyze the effect of follow-up with a familiar physician within the first month after discharge on the primary outcome of death or urgent all-cause readmission over 6 months. A familiar physician was defined as one who had seen the patient at least twice in the year before the index admission or once during the index admission. Results: In the first month after discharge, 5336 (21.9%) of the 24 373 identified patients had no follow-up visits, 16 855 (69.2%) saw a familiar physician, and 2182 (9.0%) saw unfamiliar physician(s) exclusively. The risk of death or unplanned readmission during the 6-month observation period was lower among patients who saw a familiar physician (43.6%; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.83–0.91) or an unfamiliar physician (43.6%; adjusted HR 0.90, 95% CI 0.83–0.97) for early follow-up visits, as compared with patients who had no follow-up visits (62.9%). Taking into account all follow-up visits over the 6-month period, we found that the risk of death or urgent readmission was lower among patients who had all of their visits with a familiar physician than among those followed by unfamiliar physicians (adjusted HR 0.91, 95% CI 0.85–0.98). Interpretation: Early physician follow-up after discharge and physician continuity were both associated with better outcomes among patients with heart failure. Research is needed to explore whether physician continuity is important for other conditions and in settings other than recent hospital discharge.

Association between frailty and 30-day outcomes after discharge from hospital

Background: Readmissions after hospital discharge are common and costly, but prediction models are poor at identifying patients at high risk of readmission. We evaluated the impact of frailty on readmission or death within 30 days after discharge from general internal medicine wards. Methods: We prospectively enrolled patients discharged from 7 medical wards at 2 teaching hospitals in Edmonton. Frailty was defined by means of the previously validated Clinical Frailty Scale. The primary outcome was the composite of readmission or death within 30 days after discharge. Results: Of the 495 patients included in the study, 162 (33%) met the definition of frailty: 91 (18%) had mild, 60 (12%) had moderate, and 11 (2%) had severe frailty. Frail patients were older, had more comorbidities, lower quality of life, and higher LACE scores at discharge than those who were not frail. The composite of 30-day readmission or death was higher among frail than among nonfrail patients (39 [24.1%] v. 46 [13.8%]). Although frailty added additional prognostic information to predictive models that included age, sex and LACE score, only moderate to severe frailty (31.0% event rate) was an independent risk factor for readmission or death (adjusted odds ratio 2.19, 95% confidence interval 1.12–4.24). Interpretation: Frailty was common and associated with a substantially increased risk of early readmission or death after discharge from medical wards. The Clinical Frailty Scale could be useful in identifying high-risk patients being discharged from general internal medicine wards.

Resource Use in the Last 6 Months of Life Among Patients With Heart Failure in Canada

BACKGROUND Heart failure (HF) is a debilitating and chronic condition associated with significant morbidity and mortality. However, much less is known about end-of-life (EOL) costs among patients with HF. METHODS To examine trends in resource use and costs during the last 6 months of life among elderly patients with HF, we evaluated data regarding all patients 65 years or older with HF who died between January 1, 2000, to December 31, 2006, in Alberta, Canada, and examined costs associated with all-cause hospitalizations, intensive care, emergency department visits, outpatient visits, physician office visits, and outpatient drugs in the 180 days before death. Overall costs and predictors of costs to the health care system were also examined. RESULTS The study population included 33,144 patients with HF who died. The mean age at death was 83 years. The clinical profile of patients changed during the study period, with an increasing comorbidity burden over time. Between 2000 and 2006, the percentage of patients hospitalized during the last 6 months of life decreased from 84% to 76% (P<.01); and the percentage dying in hospital decreased from 60% to 54% (P<.01). In 2006, the average EOL cost was

Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

27,983 in Canadian dollars. In multivariate analyses, increasing age was inversely associated with EOL costs and comorbid conditions were associated with higher costs. CONCLUSIONS Resource use in the last 6 months of life among patients with HF in Alberta is changing, with a reduction in hospitalizations, in-hospital deaths, and an increase in the use of outpatient services. However, EOL costs are substantial and continue to increase.