High post-discharge mortality, readmission rates persist among hospitalized HF patients

Ambrosy AP. J Am Coll Cardiol. 2014;doi:10.1016/j.jacc.2013.11.053.

  • February 17, 2014

Innovations in device and drug therapies have yielded improved outcomes for ambulatory HF patients in the past 2 decades, but high post-discharge mortality and readmission rates persist among hospitalized patients, according to data in a state-of-the-art paper recently published in the Journal of the American College of Cardiology.

The review of global hospitalized HF registries reported on patient characteristics, HF management, outcomes and prognostic indicators, differences across regions and limitations of current data.

According to the review, the mean age of patients hospitalized with a primary diagnosis of HF is 70 to 75 years, with a standard deviation of 15 years and age differences according to region. The researchers wrote that the regional differences may be related to different standards of living and underlying risks.  
Roughly 40% to 50% of HF patients were female, and the researchers said the United States had a larger proportion of female hospitalized HF patients than other areas of the world. Blacks and Hispanics account for approximately 20% and 7% of hospitalized HF patients, respectively. Although these groups have a greater overall severity and burden of HF, according to the review, risk-adjusted outcomes were comparable across various national hospital registries. The researchers also said there is little race/ethnicity data available outside of the United States.

Globally, ischemic etiology was found to be the most prevalent cause of HF, whereas in developing nations, HF is most commonly secondary to uncontrolled hypertension, congenital heart disease and valvular pathology.

Cardiac comorbidities are common worldwide among patients with hospitalized HF, according to the review. CAD is present in more than half of patients, complicated by MI in 20% to 30%, and often leading to systolic dysfunction. Hypertension and AF also are present in 70% and 40% of patients in this population, respectively. Noncardiac comorbidities also are prevalent, with diabetes, chronic kidney disease and chronic obstructive pulmonary disease observed in more than one-third of patients with hospitalized HF.

The researchers found that inpatient management for ambulatory patients with HF and reduced ejection fraction has seen few advances in recent years, with IV diuretics and/or vasodilators still the standard of treatment. The review also indicates that most hospitalized HF patients do not undergo procedural treatments during their hospital stays, and fewer than 10% of patients are assessed with coronary angiography. Median length of stay varies worldwide, from 4 to 20 days, and in-hospital mortality ranges from 4% to 30% across global registries.

Data from the OPTIMIZE-HF registry follow-up cohort indicated that the post-discharge readmission rate among hospitalized HF patients was approximately 30% within 60 to 90 days after discharge. Post-discharge mortality ranged from 5.4% to 14%, depending on systolic BP at admission. In the ESC-HF pilot survey of facilities across 12 countries in Europe, the mortality rate was 17.4% and the readmission rate was 31.9% at 1 year.

Age, comorbidities, systolic BP, renal function, serum sodium levels, hemoglobin, natriuretic peptides, troponin, QRS duration and evidence-based medication use were the most commonly accepted predictors of morbidity and mortality.

The researchers concluded that their findings underscore the need for more comprehensive long-term data on patients hospitalized with HF.

“There is currently an unmet critical need in hospitalized HF to design and conduct rational global hospital-based registries in order to better understand this heterogeneous patient population, inform public policy decisions, and guide basic, translational, and clinical research,” the researchers wrote. “… Despite the immense benefit of past [hospitalized HF] registries, there remain important knowledge gaps. It may be prudent to systematically discuss these shortcomings [and] barriers to implementation, as well as strategies for success.” They suggested a focus on geographic representation, enrollment, data capture and quality improvement interventions for future global registries.

Disclosure: See the full study for a full list of relevant financial disclosures.

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