Kismet Rasmusson

The Paradox of Obesity in Patients with Heart Failure

Purpose Heart failure (HF) patients often have comorbid conditions that confound management and adversely affect prognosis. The purpose of this study was to determine whether the obesity paradox is also present in hospitalized HF patients in an integrated healthcare system. Data sources A cohort of 2707 patients with a primary diagnosis of HF was identified within an integrated, 20‐hospital healthcare system. Patients were identified by ICD‐9 codes or a left ventricular ejection fraction ≤40% dating back to 1995. Body mass index (BMI) was calculated using the first measured height and weight when hospitalized with HF. Survival rates were calculated using Kaplan Meier estimation. Hazard ratios for 3‐year mortality with 95% confidence intervals were assessed using Cox regression, controlling for age, gender, and severity of illness at time of diagnosis. Conclusions Three‐year survival rates paradoxically improved for patients with increasing BMI. Survival rates for the larger three BMI quartiles were significantly better than for the lowest quartile after adjusting for severity of illness, age, and gender. Implications for practice While obesity increases the risk of developing HF approximately twofold, reports involving stable outpatients suggest that obesity is associated with improved survival after the development of HF. This finding is paradoxical because obesity increases the risk and worsens the prognosis of other cardiovascular diseases.

The Intermountain Risk Score (including the red cell distribution width) predicts heart failure and other morbidity endpoints

The complete blood count (CBC) and basic metabolic profile are common, low‐cost blood tests, which have previously been used to create and validate the Intermountain Risk Score (IMRS) for mortality prediction. Mortality is the most definitive clinical endpoint, but medical care is more easily applied to modify morbidity and thereby prevent death. This study tested whether IMRS is associated with clinical morbidity endpoints.

Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement from the American Heart Association

The intent of this American Heart Association (AHA) scientific statement is to summarize our current understanding of dilated cardiomyopathies. There is special emphasis on recent developments in diagnostic approaches and therapies for specific cardiomyopathies. Recommendations in this document are based on published studies, published practice guidelines from the American College of Cardiology (ACC)/AHA1 and other organizations,2,3 and the multidisciplinary expertise of the writing group. Existing evidence in epidemiology, classification, diagnosis, and management of specific cardiomyopathies is usually derived from nonrandomized observational studies, registries, case reports, or expert opinion based on clinical experience, not large-scale randomized clinical trials or systematic reviews. Therefore, in this document, rather than using the standard ACC/AHA classification schema of recommendations and level of evidence,4 we have included key management strategies at the end of each section and categorized our recommendations according to the level of consensus. Although the format of our recommendations might resemble the ACC/AHA classification of recommendations used in the ACC/AHA practice guidelines, because of the preponderance of expert opinion or level of evidence C evidence in our document, we elected to use different terminology to provide a distinction from the practice guidelines, in which stronger levels and quality of evidence with randomized clinical trials or meta-analyses are usually present.4 The levels of evidence follow the AHA and ACC methods of classifying the level of certainty of the treatment effect.4 The term dilated cardiomyopathy (DCM) refers to a spectrum of heterogeneous myocardial disorders that are characterized by ventricular dilation and depressed myocardial performance in the absence of hypertension, valvular, congenital, or ischemic heart disease.5 In clinical practice, the pathogenesis of heart failure (HF) has often been placed into 2 categories: ischemic and nonischemic cardiomyopathy. The term nonischemic cardiomyopathy has been interchangeably used with DCM. Although this …

Incremental survival benefit with adherence to standardized heart failure core measures: a performance evaluation study of 2958 patients.

BACKGROUND In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established four heart failure (HF) core measures to standardize and improve health care quality in the United States. Although adherence to these HF care processes may be improving, their collective impact on survival is not yet settled. METHODS JCAHO HF measures were implemented within a 20-hospital health care system. Eligible patients had a principal discharge diagnosis of HF. Metrics representing compliance with these measures were derived and their relationship with 1-year survival was examined using an adjusted Cox proportional hazards regression. RESULTS A total of 2958 patients met study criteria. The average age was 73 years, 50% were male, and 9.9% were smokers. One-year survival benefits were seen in an item-by-item evaluation of HF measures for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (hazard ratio [HR] = 0.69), left ventricular function assessment (HR = 0.83), and patient education (HR = 0.79). When assessed collectively, improved survival was seen among patients eligible for two (HR = 0.53), three (HR = 0.36), or four HF measures (HR = 0.65). Further, we found a positive and incremental relationship between the degree of adherence and survival (P = .008). CONCLUSION Adherence to JCAHO HF core measures is associated with improved 1-year survival after HF hospitalization. This validates these simple and effective performance measures and justifies efforts to implement them in all eligible patients with HF.

Genome-Wide Significance and Replication of the Chromosome 12p11.22 Locus Near the PTHLH Gene for Peripartum Cardiomyopathy

Background— Peripartum (PP) cardiomyopathy (CM) is a rare condition of unknown etiology that occurs in late pregnancy or early postpartum. Initial evidence suggests that genetic factors may influence PPCM. This study evaluated and replicated genome-wide association of single nucleotide polymorphisms with PPCM. Methods and Results— Genome-wide single nucleotide polymorphisms in women with verified PPCM diagnosis (n=41) were compared separately with local control subjects (n=49 postmenopausal age-discordant women with parity ≥1 and no heart failure) and iControls (n=654 women ages 30 to 84 years with unknown phenotypes). A replication study of independent population samples used new cases (PPCM2, n=30) compared with new age-discordant control subjects (local2, n=124) and with younger control subjects (n=89) and obstetric control subjects (n=90). A third case set of pregnancy-associated CM cases not meeting strict PPCM definitions (n=29) was also studied. In the genome-wide association study, 1 single nucleotide polymorphism (rs258415) met genome-wide significance for PPCM versus local control subjects (P=2.06×10−8; odds ratio [OR], 5.96). This was verified versus iControls (P=7.92×10−19; OR, 8.52). In the replication study for PPCM2 cases, rs258415 (ORs are per C allele) replicated at P=0.009 versus local2 control subjects (OR, 2.26). This replication was verified for PPCM2 versus younger control subjects (P=0.029; OR, 2.15) and versus obstetric control subjects (P=0.013; OR, 2.44). In pregnancy-associated cardiomyopathy cases, rs258415 had a similar effect versus local2 control subjects (P=0.06; OR, 1.79), younger control subjects (P=0.14; OR, 1.65), and obstetric control subjects (P=0.038; OR, 1.99). Conclusions— Genome-wide association with PPCM was discovered and replicated for rs258415 at chromosome 12p11.22 near PTHLH. This study indicates a role of genetic factors in PPCM and provides a new locus for further pathophysiological and clinical investigation.

Peripartum cardiomyopathy: post-transplant outcomes from the United Network for Organ Sharing Database.

BACKGROUND Nearly 25% of patients with peripartum cardiomyopathy (PPCM) will require cardiac transplantation. Whether post-transplant outcomes differ among patients with PPCM compared with other recipients remains unsettled. METHODS The United Network for Organ Sharing database was queried for cardiac transplants, comparing characteristics and outcomes for PPCM, other women, and all others. RESULTS Between 1987 and 2010, 42,406 patients (9,419 women and 32,987 men) received a heart transplant. Of these, 485 women who had PPCM as the indication were younger (p < 0.001), had higher sensitization (p < 0.001), required higher intensity of cardiovascular support pre-transplant (p = 0.026), and had higher listing status (p < 0.001). Those with PPCM had more post-transplant rejection during the index transplant hospitalization (p < 0.001) and during the first year (p = 0.003). Comparing PPCM with other women and all others, graft survival was inferior (p = 0.004 and p < 0.003, respectively) and age-adjusted survival was lower (p < 0.001 and p = 0.02, respectively). CONCLUSIONS This large report shows outcomes of graft failure and death are inferior for recipients with PPCM, which may be partly explained by younger age, higher allosensitization, higher pre-transplant acuity, and increased rejection. More research is needed to determine management strategies to improve outcomes in PPCM heart transplant recipients.

Automated identification and predictive tools to help identify high-risk heart failure patients: pilot evaluation

OBJECTIVE Develop and evaluate an automated identification and predictive risk report for hospitalized heart failure (HF) patients. METHODS Dictated free-text reports from the previous 24 h were analyzed each day with natural language processing (NLP), to help improve the early identification of hospitalized patients with HF. A second application that uses an Intermountain Healthcare-developed predictive score to determine each HF patients risk for 30-day hospital readmission and 30-day mortality was also developed. That information was included in an identification and predictive risk report, which was evaluated at a 354-bed hospital that treats high-risk HF patients. RESULTS The addition of NLP-identified HF patients increased the identification scores sensitivity from 82.6% to 95.3% and its specificity from 82.7% to 97.5%, and the models positive predictive value is 97.45%. Daily multidisciplinary discharge planning meetings are now based on the information provided by the HF identification and predictive report, and clinicians review of potential HF admissions takes less time compared to the previously used manual methodology (10 vs 40 min). An evaluation of the use of the HF predictive report identified a significant reduction in 30-day mortality and a significant increase in patient discharges to home care instead of to a specialized nursing facility. CONCLUSIONS Using clinical decision support to help identify HF patients and automatically calculating their 30-day all-cause readmission and 30-day mortality risks, coupled with a multidisciplinary care process pathway, was found to be an effective process to improve HF patient identification, significantly reduce 30-day mortality, and significantly increase patient discharges to home care.

American Association of Heart Failure Nurses Position Paper on Educating Patients with Heart Failure

Heart failure (HF) affects nearly 6 million Americans, a number projected to increase by 46% in the year 2030.1 The diagnosis of HF necessitates that patients and families develop self-care skills and adopt lifestyle changes that facilitate controlling symptoms and slowing the progression of the disorder.2,3 These lifestyle changes include: managing a prescribed medication regimen; recognizing signs and symptoms of worsening HF; making dietary changes and adopting an individually tailored exercise program.2,3 In order to engage in self-care, persons with HF and their support systems need to acquire knowledge and skills specific to the health problem and the various pharmacologic therapies, devices, and nonpharmacologic interventions that are part of overall HF disease management.4 The aim of these efforts is to improve quality of life5 and increase survival. Thus, patient and family education is essential to prepare patients with HF for self-care. The American Nurses Association (ANA) Scope and Standards of Cardiovascular Nursing identifies patient education as a fundamental responsibility of the nurse.6 Since its inception in 2004, The American Association of Heart Failure Nurses (AAHFN) has been a participating organization in the development of all editions of the Cardiovascular Scope and Standards that guide HF nursing practice. Furthermore, multidisciplinary guidelines for the treatment of patients with HF include patient education as a highly recommended non-pharmacologic treatment.7e9 In addition, adherence with national standards that address patient education are required for program accreditation10 and certification.11e13 Heart failure discharge instructions for patients has been defined by The Joint Commission to include six topics: diet, exercise, weight monitoring, worsening symptoms, medications and follow up appointments.10,12 Thus, comprehensive patient education has been solidified as essential to patient care and is a responsibility of nursing.14 Heart failure patient education has had increased awareness and efforts to complete documentation of “discharge instructions”,15 yet such education has been performed using varied methods with uncertain effectiveness.11,12,16,17 Meaningful

The intermountain risk score predicts incremental age-specific long-term survival and life expectancy

The Intermountain Risk Score (IMRS) encapsulates the mortality risk information from all components of the complete blood count (CBC) and basic metabolic profile (BMP), along with age. To individualize the IMRS more clearly, this study evaluated whether IMRS weightings for 1-year mortality predict age-specific survival over more than a decade of follow-up. Sex-specific 1-year IMRS values were calculated for general medical patients with CBC and BMP laboratory tests drawn during 1999-2005. The population was divided randomly 60% (N = 71,921, examination sample) and 40% (N = 47,458, validation sample). Age-specific risk thresholds were established, and both survival and life expectancy were compared across low-, moderate-, and high-risk IMRS categories. During 7.3 ± 1.8 years of follow-up (range, 4.5-11.1 years), the average IMRS of decedents was higher than censored in all age/sex strata (all P < 0.001). For examination and validation samples, every age stratum had incrementally lower survival for higher risk IMRS, with hazard ratios of 2.5-8.5 (P < 0.001). Life expectancies were also significantly shorter for higher risk IMRS (all P < 0.001): For example, among 50-59 year-olds, life expectancy was 7.5, 6.8, and 5.9 years for women with low-, moderate-, and high-risk IMRS (with mortality in 5.7%, 16.3%, and 37.0% of patients, respectively). In Men, life expectancy was 7.3, 6.8, and 5.4 for low-, moderate-, and high-risk IMRS (with patients having 7.3%, 19.5%, and 40.0% mortality), respectively. IMRS significantly stratified survival and life expectancy within age-defined subgroups during more than a decade of follow-up. IMRS may be used to stratify age-specific risk of mortality in research, clinical/preventive, and quality improvement applications. A web calculator is located at http://intermountainhealthcare.org/IMRS.

HFSA and AAHFN Joint Position Statement: Advocating for a Full Scope of Nursing Practice and Leadership in Heart Failure

The Heart Failure Society of America (HFSA) and theAmerican Association of Heart Failure Nurses (AAHFN)share a common core mission to improve outcomes ofpatients with heart failure. A recent report underscoredthe importance of increasing advocacy efforts to enablenurses to practice to the full extent of their education andtraining and engage in full partnership with physiciansand other health professionals in redesigning health care.