Lifetime Analysis of Hospitalizations and Survival of Patients Newly Admitted With Heart Failure

Abstract

Background Hospital readmissions for heart failure (HF) contribute to increased morbidity and resource burden. Predictors of hospitalization and patterns of cardiovascular events over the lifetime of patients with HF have not been elucidated. Methods and Results We examined recurrent hospitalizations, cardiovascular events, and survival among newly discharged (April 1999–March 2001) patients with HF in the Enhanced Feedback For Effective Cardiac Treatment phase 1 study. During 10-year follow-up, we examined all new cardiovascular hospitalizations and selected predictors of readmission. Among 8543 patients (mean age, 77.4±10.5 years; 51.6% women) followed for 22 567 person-years, 60.7% had ischemic etiology, and 67.3% had HF with reduced ejection fraction (left ventricular ejection fraction ≤45% versus >45% [HF with preserved ejection fraction]). Overall, 10-year mortality was 98.8%, with 35 966 hospital readmissions occurring over the lifetime of the cohort. Adjusted hazards ratios (HRs) for first cardiovascular hospitalization were 1.36 for ischemic HF (95% CI, 1.28–1.44; P<0.001), 1.10 for HF with reduced ejection fraction (95% CI; 1.00–1.20; P=0.045), and 1.00 for men (95% CI, 0.94–1.06; P=0.979). On repeated-events time-to-event analysis, ischemic HF was a predictor of cardiovascular (HR, 1.24; 95% CI, 1.18–1.29), HF (HR, 1.20; 95% CI, 1.13–1.27), and coronary heart disease (HR, 2.01; 95% CI, 1.81–2.24) hospitalizations (all P<0.001). Of all recurrent HF hospitalizations, 26.8% occurred in the first and 39.8% in the last deciles of cohort survival duration. Similarly, 29.7% and 52.3% of all cardiovascular readmissions occurred in the first and last deciles of the cohort survival duration, respectively. Conclusions Among newly discharged patients with HF, cardiovascular events were clustered at early postdischarge and prefatal time periods, and were increased among those with ischemic etiology.

Rehospitalization for Heart Failure

“…16 Data from trials of implantable hemodynamic monitors confirm that the risk for heart failure events is tightly coupled to the degree of chronic filling pressure elevation, with progressively higher risk once the median 24-hour pulmonary artery diastolic pressure rises Ͼ18 mm Hg. 17 Chun et al 7 have elegantly outlined a 3-phase terrain of lifetime risk for readmission based on analysis of a cohort of 8543 newly discharged Canadian patients with heart failure (see Figure 1). 18 In this community-dwelling population, 30% of all cardiovascular readmissions occurred within the first 2 months of hospital discharge, and 50% occurred within the 2 months before death, with much lower admission rates (15%-20%) observed in the intercurrent plateau phase.…”

“…7,19 Strategies that are effective in reducing rehospitalization rates earlier in the postdischarge trajectory are less likely to be effective for those who have progressed to the advanced stages of illness despite optimal therapy. Hypotension and renal dysfunction may render patients less tolerant of previous neurohormonal antagonist therapies and less responsive to escalating diuretic therapy.…”

“…1 Despite dramatic improvement in outcomes with medical therapy, 2,3 admission rates following heart failure hospitalization remain high, 4 with Ն50% patients readmitted to hospital within 6 months of discharge. [5][6][7] Because reduction in readmission rates might simultaneously reduce costs and improve quality of care, public and private payers have increasingly targeted readmissions as a focus of pay-for-performance initiatives. 8 In 2009, the US Center for Medicare & Medicaid Services began public reporting of all-cause readmission rates after heart failure hospitalization, and, in the following year, the Patient Protection and Affordable Care Act 9 established financial penalties for hospitals with the highest readmission rates during the first 30 days after discharge.…”

Influence of Sacubitril/Valsartan (LCZ696) on 30-Day Readmission After Heart Failure Hospitalization

“…Although patients discharged with HF are at risk for readmission well beyond 30 days, the early post-discharge interval is known to be a particularly vulnerable period (11,12). In the United States, TRANSLATIONAL OUTLOOK: Future studies should seek to clarify the mechanism by which composite angiotensin receptorneprilysin inhibition exerts benefit beyond the acute hospital phase of treatment compared with angiotensin-converting enzyme inhibition alone in patients with progressive heart failure and reduced ejection fraction.…”

Regional variation in hospitalisation and mortality in heart failure: comparison of England and Lombardy using multistate modelling

“…However, 30 days is an arbitrary follow-up period and patients are at risk of poor outcomes for longer [8]. In addition, many patients have multiple readmissions, sometimes over a period of several years, so this measure loses information, especially on disease progression [9]. Most studies of readmissions ignore the competing risk of death or account for it by using a combined endpoint of death or readmission [10], which is unsatisfactory, not least because death and readmission are far from being of equal importance.…”