Background: Readmission to hospitals for heart failure is one of the greatest economic burdens on Medicare, and has become a major focus of healthcare reform. In an attempt to stem the overwhelming number of readmissions and improve heart failure outcomes, hospitals have employed multiple interventions. Nurse-led heart failure management programs have been an effective strategy in reducing hospital readmissions for heart failure. Purpose:We conducted an integrative review of the literature that assessed the value of interventions to reduce heart failure readmission rates. We focused on the important role of nursing care in successfully implementing many of these interventions.Methods: An integrative review of the literature was performed. A computerized search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library (reviews and clinical trials) was performed to locate articles published from 2004 to 2014. Key words used included "heart failure nursing", "heart failure readmissions", "heart failure programs" and "interventions for heart failure readmission". Preference was placed on articles published in the last 10 years. Articles referenced by national heart failure guideline documents and expert consensus statements were given a high priority. Eighty-eight articles were screened initially by two reviewers; these were then screened to leave 40 relevant articles. Conclusions:Several specific interventions have a proven favorable effect in reducing heart failure readmissions. These include optimal medical management, patient education and self-care instruction, and ensuring adequate post-discharge follow-up. Despite this knowledge there remains a wide variation of readmission rates across the United States. This may be partly due to the variability in the adequate implementation of interventions and/or the absence of a required number of interventions in different centers. Each single intervention in itself has only a very small beneficial effect. The implementation of several interventions is essential to produce a meaningful reduction in heart failure readmissions. The ability to successfully employ numerous interventions together may explain the promising results of structured nurse-led heart failure programs.

Results: Mean age was 73.06 6.0 years and 53% were women. There were 3532 (50%) deaths over a median follow-up of 2.01 years (Table 1). Elderly subjects with CAD having normal BMI but with central obesity (high WHR) have the highest mortality risk than any other combination of BMI and WHR (2.86; 2.26-3.63) ( Figure 1A). WC alone or in combination with BMI did not show statistically significant results (Table 2). BMI alone was inversely associated with mortality. Women were three times and men were two times as likely to die as compared to their gender specific counterparts in first tertile based on WHR (Figure 2). Analysis of two-year mortality showed similar results ( Figure 1B). Conclusions:In older adults with CAD, the ''obesity paradox'' is present and NWCO, as measured by WHR, and not by WC, is associated with the highest risk of mortality. The study highlights the need to combine measures of total and central obesity in adiposity-related risk assessment of older adults. 191Is 0.5 the