Predicting one-year mortality among elderly survivors of hospitalization for an acute myocardial infarction: results from the Cooperative Cardiovascular Project

AbstractOBJECTIVESWe sought to develop a model based on information available from the medical record that would accurately stratify elderly patients who survive hospitalization with an acute myocardial infarction (AMI) according to their risk of one-year mortality.BACKGROUNDPrediction of the risk of mortality among older survivors of an AMI has many uses, yet few studies have determined the prognostic importance of demographic, clinical and functional data that are available on discharge in a population-based sample.METHODSIn a cohort of patients aged ≥65 years who survived hospitalization for a confirmed AMI from 1994 to 1995 at acute care, nongovernmental hospitals in the U.S., we developed a parsimonious model to stratify patients by their risk of one-year mortality.RESULTSThe study sample of 103,164 patients, with a mean age of 76.8 years, had a one-year mortality of 22%. The factors with the strongest association with mortality were older age, urinary incontinence, assisted mobility, presence of heart failure or cardiomegaly any time before discharge, presence of peripheral vascular disease, body mass index <20 kg/m2, renal dysfunction (defined as creatinine >2.5 mg/dl or blood urea nitrogen >40 mg/dl) and left ventricular dysfunction (left ventricular ejection fraction <40%). On the basis of the coefficients in the model, patients were stratified into risk groups ranging from 7% to 49%.CONCLUSIONSWe demonstrate that a simple risk model can stratify older patients well by their risk of death one year after discharge for AMI

Outcomes in heart failure patients with preserved ejection fraction Mortality, readmission, and functional decline

AbstractObjectivesWe evaluated the six-month clinical trajectory of patients hospitalized for heart failure (HF) with preserved ejection fraction (EF), as the natural history of this condition has not been well established. We compared mortality, hospital readmission, and changes in functional status in patients with preserved versus depressed EF.BackgroundAlthough the poor prognosis of HF with depressed EF has been extensively documented, there are only limited and conflicting data concerning clinical outcomes for patients with preserved EF.MethodsWe prospectively evaluated 413 patients hospitalized for HF to determine whether EF ≥40% was an independent predictor of mortality, readmission, and the combined outcome of functional decline or death.ResultsAfter six months, 13% of patients with preserved EF died, compared with 21% of patients with depressed EF (p = 0.02). However, the rates of functional decline were similar among those with preserved and depressed EF (30% vs. 23%, respectively; p = 0.14). After adjusting for demographic and clinical covariates, preserved EF was associated with a lower risk of death (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.26 to 0.90; p = 0.02), but there was no difference in the risk of readmission (HR 1.01, 95% CI 0.72 to 1.43; p = 0.96) or the odds of functional decline or death (OR 1.01, 95% CI 0.59 to 1.72; p = 0.97).ConclusionsHeart failure with preserved EF confers a considerable burden on patients, with the risk of readmission, disability, and symptoms subsequent to hospital discharge, comparable to that of HF patients with depressed EF

Randomized trial of an education and support intervention to preventreadmission of patients with heart failure

AbstractObjectivesWe determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure (HF).BackgroundDisease management programs for patients with HF including medical components may reduce readmissions by 40% or more, but the value of an intervention focused on education and support is not known.MethodsWe conducted a prospective, randomized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF.ResultsAmong the 88 patients (44 intervention and 44 control) in the study, 25 patients (56.8%) in the intervention group and 36 patients (81.8%) in the control group had at least one readmission or died during one-year follow-up (relative risk = 0.69, 95% confidence interval [CI]: 0.52, 0.92; p = 0.01). The intervention was associated with a 39% decrease in the total number of readmissions (intervention group: 49 readmissions; control group: 80 readmissions, p = 0.06). After adjusting for clinical and demographic characteristics, the intervention group had a significantly lower risk of readmission compared with the control group (hazard ratio = 0.56, 95% CI: 0.32, 0.96; p = 0.03) and hospital readmission costs of $7,515 less per patient.ConclusionsA formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF

Leveraging clinical decision support tools to improve guideline-directed medical therapy in patients with atherosclerotic cardiovascular disease at hospital discharge

Background: Guidelines recommend moderate to high-intensity statins and antithrombotic agents in patients with atherosclerotic cardiovascular disease (ASCVD). However, guideline-directed medical therapy (GDMT) remains suboptimal. Methods: In this quality initiative, best practice alerts (BPA) in the electronic health record (EHR) were utilized to alert providers to prescribe to GDMT upon hospital discharge in ASCVD patients. Rates of GDMT were compared for 5 months pre- and post-BPA implementation. Multivariable regression was used to identify predictors of GDMT. Results: In 5985 pre- and 5568 post-BPA patients, the average age was 69.1 ± 12.8 years and 58.5% were male. There was a 4.0% increase in statin use from 67.3% to 71.3% and a 3.1% increase in antithrombotic use from 75.3% to 78.4% in the post-BPA cohort.  Conclusions: This simple EHR-based initiative was associated with a modest increase in ASCVD patients being discharged on GDMT. Leveraging clinical decision support tools provides an opportunity to influence provider behavior and improve care for ASCVD patients, and warrants further investigation

Quality of Care for Heart Failure Patients Hospitalized for Any Cause

The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes

COLD GASS, an IRAM legacy survey of molecular gas in massive galaxies: I. Relations between H2, HI, stellar content and structural properties

We are conducting COLD GASS, a legacy survey for molecular gas in nearby galaxies. Using the IRAM 30m telescope, we measure the CO(1-0) line in a sample of ~350 nearby (D=100-200 Mpc), massive galaxies (log(M*/Msun)>10.0). The sample is selected purely according to stellar mass, and therefore provides an unbiased view of molecular gas in these systems. By combining the IRAM data with SDSS photometry and spectroscopy, GALEX imaging and high-quality Arecibo HI data, we investigate the partition of condensed baryons between stars, atomic gas and molecular gas in 0.1-10L* galaxies. In this paper, we present CO luminosities and molecular hydrogen masses for the first 222 galaxies. The overall CO detection rate is 54%, but our survey also uncovers the existence of sharp thresholds in galaxy structural parameters such as stellar mass surface density and concentration index, below which all galaxies have a measurable cold gas component but above which the detection rate of the CO line drops suddenly. The mean molecular gas fraction MH2/M* of the CO detections is 0.066+/-0.039, and this fraction does not depend on stellar mass, but is a strong function of NUV-r colour. Through stacking, we set a firm upper limit of MH2/M*=0.0016+/-0.0005 for red galaxies with NUV-r>5.0. The average molecular-to-atomic hydrogen ratio in present-day galaxies is 0.3, with significant scatter from one galaxy to the next. The existence of strong detection thresholds in both the HI and CO lines suggests that "quenching" processes have occurred in these systems. Intriguingly, atomic gas strongly dominates in the minority of galaxies with significant cold gas that lie above these thresholds. This suggests that some re-accretion of gas may still be possible following the quenching event.Comment: Accepted for publications in MNRAS. 32 pages, 25 figure