Evaluation of Guideline-Directed Medication Therapy for Heart Failure with Reduced Ejection Fraction Patients at Discharge on 30-Day Readmission Rates at Two Tertiary Healthcare Centers

Evaluation of Guideline-Directed Medication Therapy for Heart Failure with Reduced Ejection Fraction Patients at Discharge on 30-Day Readmission Rates at Two Tertiary Healthcare Centers Principal Investigator: Jacqueline Hesse, Pharm.D. Preceptors: Yan Xu, Pharm.D., BCPS, BCCP; Meri Slavica, Ph.D., BCPS Pharmacy Student: James Watkins, 2020 Pharm.D. Candidate Sub-Investigators: Alan Rankin, MD; Joshua Remick, MD Background: Heart failure with reduced ejection fraction (HFrEF) is a chronic, progressive disease leading to symptoms such as dyspnea, cough, edema, fatigue, and exercise intolerance. The use of anangiotensin converting enzyme inhibitor (ACEi), angiotensin II receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNI) in combination with an evidence-based beta blocker (BB) is guideline-supported Class I recommended therapy for HFrEF with an LVEF Methods: A retrospective chart review was completed using the Epic Electronic Medical Record of all patients admitted to one of our tertiary medical centers between January 1, 2018 and December 31, 2019 with a primary diagnosis of HFrEF. Patients were included if they were at least 18 years of age and had an LVEF of Results A total of 1,999 patient admissions underwent chart review with 752 admissions not meeting inclusion criteria and 1,247 admissions being included in the final analysis. Of those included, 202 patients (16%) were readmitted within 30 days. Patients discharged with any GDMT had less readmissions within 30 days than those without any GDMT (OR 0.6, 95% CI 0.4-1.0, p = 0.0369). However, patients discharged on an ACEi or ARB had more readmissions within 30 days than patients discharged on no GDMT (OR 1.4, 95% CI 1.0-1.9, p = 0.0283). 49% of patients (N = 609) had an idiopathic cause of heart failure followed by 32% of patients with non-ischemic cardiomyopathy (N = 394) and 20% of patients with ischemic cardiomyopathy (N = 244). No significant differences were found between the 30-day readmission rate and cause of heart failure. For highest K value on readmission, no significant differences were found between groups. For highest SCr on readmission, discharging on an ACEi or ARB or discharging on an ACEi or ARB in combination with a BB yielded a significantly lower SCr on readmission compared to no GDMT (1.6 vs. 2.6, p = Conclusion In conclusion, patients admitted with a primary diagnosis of HFrEF that are discharged on any GDMT were found to have less readmissions for any reason within 30 days than those without any GDMT. However, subgroup analysis for individual GDMT may not have a lower rate of readmissions. Further research with prospective randomized controlled trials is needed to determine statistical significance of subgroups of GDMT on the rate of readmission within 30 days.https://digitalcommons.psjhealth.org/pharmacy_PGY1/1010/thumbnail.jp

Implementation of a Cardiogenic Shock Protocol and Data Review Process is Associated With Improved In-Hospital Survival

Background: Despite increasing use of mechanical circulatory support devices (MCS), cardiogenic shock (CS) mortality is persistently high, with worsening outcomes in later stages of CS. Delays in diagnosis and practice variation may contribute to in-hospital mortality. Methods: In June 2018, we devised and implemented a CS protocol at two hospitals from one health system in Portland, OR. The CS protocol was designed to promote early CS recognition, rapid notification of a multi-disciplinary specialty team lead by a heart failure cardiologist, invasive hemodynamic evaluation, and institution of MCS as appropriate. CS was defined by widely accepted clinical and hemodynamic criteria. Patient demographics, disease severity, process metrics, and clinical outcomes were prospectively collected and reviewed monthly by a multi-disciplinary CS task force. M&Ms were conducted routinely to identify improvement opportunities. The task force continually refined data collection, implemented protocol improvements, and educated providers and clinical staff in the emergency department, critical care, intermediate care, and cardiac telemetry units. Education centered on early recognition of CS, protocol for activation, and the time-sensitivity of CS outcomes. Results: From June 1, 2018 to October 1, 2019, identification of CS patients grew from five to 55 patients per month, with 311 total patients identified. Education initially emphasized CS identification and team activation, then expanded to definition of CS stages and hospital-specific protocols. Over 10 months, the CS mortality rate decreased by 30%. Ongoing optimization includes stratifying patients by primary discharge diagnosis, consistently documenting shock stages in the electronic medical record, and refining the transfer process from other hospitals. Conclusions: Implementation of a CS protocol with emphasis on early recognition, hemodynamic assessment, and implementation of MCS is associated with improved survival. Multi-disciplinary education and team engagement in data review are integral to continual process improvement. Character count: 1,818 Clinical Implications: A protocolized, multi-disciplinary approach can improve the outcome of CS

Hemodynamic, Therapeutic, and Clinical Outcomes of Ambulatory Pressure-Guided Heart Failure Management

Background Heart failure (HF) management guided by CardioMEMS™ pulmonary artery pressure (PAP) monitoring reduces PAP and HF hospitalizations. The objective of this project was to characterize the relationship between medication adjustments, PAP change, and outcomes for all patients at an advanced HF center. Methods We retrospectively analyzed medication changes and hospitalizations for 32 consecutive patients implanted with the CardioMEMS™ sensor at a single HF center and related these outcomes to PAP data from the Merlin.net (Abbott) database. Absolute change in PAP from baseline was estimated using area under the curve normalized to days monitored. Results Patients had an average change in mean PAP of -3.9±1.3 mmHg at 6 months and -5.7±2.1 mmHg at 12 months. Compared to the pre-implant time period, hospital days for HF-related hospitalizations decreased by 6.9 (95% CI = 3.3-10.5) days per patient at 6 months (p\u3c0.001) and 7.9 (95% CI = 4.3-11.5) days per patient at 12 months (p\u3c0.001). Over 12 months, patients with baseline PAP 25-35mmHg and \u3e35mmHg experienced a drop in PAP while their number of medication adjustments decreased, and patients with baseline PAP \u3c25mmHg experienced a rise in PAP and an increase in medication adjustments. Conclusion PAP-guided HF management involved time-varying intensity of medication changes, which correlated with sustained reductions in hospital stay

Abstract 13055: Ambulatory Pressure-Guided Heart Failure Management at an Advanced Heart Failure Program Shows Benefit Across Baseline Pressure Ranges

Introduction: Heart failure (HF) management guided by pulmonary artery pressure (PAP) monitoring using the CardioMEMS™ system has been shown to reduce PAP and HF hospitalization (HFH). Our aim was to examine the relationship between medical management, PAP change, and clinical outcomes in a single cohort of CardioMEMS™ patients in our advanced HF program. Methods: We conducted retrospective analyses of PAP data (Abbott) and chart review of hospitalizations and total medication adjustments for 32 patients implanted with CardioMEMS™ at a non-transplant center. PAP change from baseline was estimated using area under the curve methodology. Rates of HFH within 6 and 12 months pre- and post-implant were compared using the Anderson-Gill regression modeling for recurrent events and presented as hazard ratio (HR) [95% CI]. Changes in PAP vs intensity of medication adjustments over time were graphed according to baseline pressure groups. Results: Median age was 66 years (range 40-88), 50% were female, and 37.5% had preserved ejection fraction. Six patients (19%) had baseline PAP \u3c25 mmHg, 13 patients (41%) had baseline PAP 25-35 mmHg, and 13 patients (41%) had baseline PAP ≥35 mmHg. The average change in mean PAP was -3.9±1.3 mmHg at 6 months (n=27) and -5.7±2.1 mmHg at 12 months (n=18). Adjustments in loop diuretics (53.9%, 152 adjustments) were most common. After implant, the risk of HFH decreased by 81% in 6 months (HR = 0.19 [0.10-0.37]; p\u3c0.001) and 72% in 12 months (HR = 0.28 [0.14-0.55]; p=0.002). Patients with high baseline PAP had a high number of medication adjustments in the first 3 months, which effectively reduced PAP in subsequent months (Figure 1). Conversely, patients with low baseline PAP had increased medication adjustments and rising PAP over time. Conclusions: PAP-guided HF management reduced PAP and HFH across pressure ranges in a real-world setting. The intensity of medication adjustments needed differed by patients’ baseline PAP

Temporal shift in heart failure diagnoses among hospitalized patients within a large US integrated health system

Background: Heart failure (HF) is a major cause of morbidity and mortality. Its rising prevalence and attributable cost have also made it a key focus in value-based care.Historically, most HF admissions among Medicare beneficiaries in the US have been disproportionately accounted for by a limited number of International Classification of Disease (ICD) diagnosis codes (I50.2, systolic heart failure; I50.3, diastolic heart failure; and I50.4, combined systolic and diastolic heart failure). In 2017, however, a significant shift in assigned codes was observed nationally, with hypertensive heart disease with heart failure (I11.0) and hypertensive heart disease with heart failure and chronic kidney disease (I13.0 and I13.2) accounting for a large majority of assigned ICD-10 codes (1).Purpose: To better understand the pattern of assigned ICD-10 codes among patients hospitalized for HF since 2017.Methods: We performed a retrospective cross-sectional analysis of patients admitted to a large integrated health system within the western US between 1/1/2018 and 10/1/2022 with a principal diagnosis of HF (defined by one of the above ICD-10 codes). More specifically, we sought to further understand the demographics, clinical characteristics, and treatment patterns of HF patients across all payers as part of a quality improvement initiative. Patient-level analyses were not performed; rather, all hospitalizations were considered independent events.Results: Over the nearly 5-year period, 61,238 HF hospitalizations occurred, involving 43,234 patients, with 76% having more than 1 hospitalization. Hypertensive heart disease with HF and chronic kidney disease was the most common HF diagnosis, accounting for just over half of all admissions (Figure). Hypertensive heart disease with HF was the next most common HF diagnosis, accounting for just over one-third of admissions. Consistent with the previous observed shift in HF diagnoses among US Medicare beneficiaries in 2017, systolic HF, diastolic HF, and combined systolic and diastolic HF accounted for \u3c10% of HF admissions in 2022.Conclusions: Hypertensive heart disease with HF and chronic kidney disease and hypertensive heart disease with HF now constitute the predominant HF diagnoses for hospitalized patients across payers. This has important implications for quality improvement initiatives and health services research that utilize real-world data, as precise characterization of distinct phenotypes of HF may now be less reliant on coding than before

Abstract 14436: Right Interval Jugular Access for Cardiomems™ Implantation is Safe, Effective, and Fast

Introduction: The CardioMEMS™ pulmonary artery pressure sensor is FDA approved for insertion via the femoral vein. The right internal jugular vein (IJ) is an alternative access route used frequently by heart failure cardiologists. The IJ approach obviates the need for patient immobilization for hemostasis and has been shown to be effective in a single center study. Hypothesis: CardioMEMS™ IJ access has comparable efficacy and safety to femoral access, while allowing for shorter discharge time. Methods: This was a retrospective analysis of patient and procedural data from 10 providers at 4 high-volume centers that routinely implant the CardioMEMS™ sensor via IJ approach. Outcomes including fluoroscopy time, deployment time, case time, case complications, time to discharge, and rates of same day discharge were compared between IJ and femoral approaches using Wilcoxon rank sum test for continuous variables and Chi-square or Fisher’s exact test for categorical variables. Regression analyses were conducted to identify and control for confounders. Results: Median age was 69 years (range 30-91) and 48% of patients were female. Seventy two (33%) patients had femoral access and 148 (67%) had IJ access; demographics were similar between the groups. Unadjusted outcomes showed IJ cases finished 17 minutes faster, discharged 19 hours faster overall and 4 hours faster for outpatient cases (Table 1). Complications and 30 day mortality were low and did not differ between cohorts. After adjusting for confounders, the median time to case completion for the IJ approach was 12% (95% CI: 3-21%) shorter than the femoral approach (p=0.01). Confounder-adjusted outcomes showed outpatients who had femoral approach were 96% (95% CI: 67-99%) less likely to have same day discharge than outpatients who had IJ approach (p\u3c0.001). Conclusions: In a multi-center study, we found that IJ access for CardioMEMS™ implant is associated with shorter procedure time and higher rates of same-day discharge

Internal Jugular Vein as Alternative Access for Implantation of a Wireless Pulmonary Artery Pressure Sensor.

BACKGROUND: A wireless pulmonary artery pressure sensor (CardioMEMS) is approved for implantation via the femoral vein. The internal jugular vein (IJ) is an attractive alternative access route commonly used in pulmonary artery catheterization. METHODS AND RESULTS: Retrospective chart review was performed for all sensor implants from 10 providers at 4 centers from September 2016 to June 2018. To compare procedural outcomes and discharge efficiency between groups, multivariate analyses incorporating potential confounders were performed. Seventy-three (28%) patients had femoral access, and 189 (72%) had IJ access; demographics were similar between the groups. Complications, including one case of hematoma and 4 cases of mild hemoptysis, and 30-day mortality (2%-3%) did not differ between groups. Provider preference for IJ access substantially increased over time, with IJ accounting for 90% of cases in 2018. After risk-adjustment, IJ cases had 20% (5%-33%) shorter fluoroscopy time ( CONCLUSIONS: IJ access for CardioMEMS implant is a safe alternative associated with superior procedural and discharge outcomes. Implanters at 4 high-volume centers adopted IJ access as the preferred implant approach