A review of interventions to improve clinical outcomes following hospitalisation for heart failure

Heart failure (HF) is a leading cause of hospitalisation and death among older adults in high-income countries. HF is often accompanied by comorbid conditions, and patients hospitalised for HF commonly die or are readmitted in the weeks follow- ing hospital discharge. The objectives of this paper are to discuss the burden of HF hospitalisations in healthcare systems and to review strategies that reduce hospitalisations and death in this condition

Temporal Trends and Clinical Trial Characteristics Associated with the Inclusion of Women in Heart Failure Trial Steering Committees:A Systematic Review

Background: Trial steering committees (TSCs) steer the conduct of randomized controlled trials (RCTs). We examined the gender composition of TSCs in impactful heart failure RCTs and explored whether trial leadership by a woman was independently associated with the inclusion of women in TSCs. Methods: We systematically searched MEDLINE, EMBASE, and CINAHL for heart failure RCTs published in journals with impact factor ≥10 between January 2000 and May 2019. We used the Jonckheere-Terpstra test to assess temporal trends and multivariable logistic regression to explore trial characteristics associated with TSC inclusion of women. Results: Of 403 RCTs that met inclusion criteria, 127 (31.5%) reported having a TSC but 20 of these (15.7%) did not identify members. Among 107 TSCs that listed members, 56 (52.3%) included women and 6 of these (10.7%) restricted women members to the RCT leaders. Of 1213 TSC members, 11.1% (95% CI, 9.4%-13.0%) were women, with no change in temporal trends (P=0.55). Women had greater odds of TSC inclusion in RCTs led by women (adjusted odds ratio, 2.48 [95% CI, 1.05-8.72], P=0.042); this association was nonsignificant when analysis excluded TSCs that restricted women to the RCT leaders (adjusted odds ratio 1.46 [95% CI, 0.43-4.91], P=0.36). Conclusions: Women were included in 52.3% of TSCs and represented 11.1% of TSC members in 107 heart failure RCTs, with no change in trends since 2000. RCTs led by women had higher adjusted odds of including women in TSCs, partly due to the self-inclusion of RCT leaders in TSCs

Heart Failure Readmission in Patients With ST-Segment Elevation Myocardial Infarction and Active Cancer

BackgroundAlthough numerous studies have examined readmission with heart failure (HF) after acute myocardial infarction (AMI), limited data are available on HF readmission in cancer patients post-AMI. ObjectivesThis study aimed to assess the rates and factors associated with HF readmission in cancer patients presenting with ST-segment elevation myocardial infarction (STEMI). MethodsA nationally linked cohort of STEMI patients between January 2005 and March 2019 were obtained from the UK Myocardial Infarction National Audit Project registry and the UK national Hospital Episode Statistics Admitted Patient Care registry. Multivariable Fine-Gray competing risk models were used to evaluate HF readmission at 30 days and 1 year. ResultsA total of 326,551 STEMI indexed admissions were included, with 7,090 (2.2%) patients having active cancer. The cancer group was less likely to be admitted under the care of a cardiologist (74.5% vs 81.9%) and had lower rates of invasive coronary angiography (62.2% vs 72.7%; P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%). There was a significant prescription gap in the administration of post-AMI medications upon discharge such as an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (49.5% vs 71.1%) and beta-blockers (58.4% vs 68.0%) in cancer patients. The cancer group had a higher rate of HF readmission at 30 days (3.2% vs 2.3%) and 1 year (9.4% vs 7.3%). However, after adjustment, cancer was not independently associated with HF readmission at 30 days (subdistribution HR: 1.05; 95% CI: 0.86-1.28) or 1 year (subdistribution HR: 1.03; 95% CI: 0.92-1.16). The opportunity-based quality indicator was associated with higher rates of HF readmission independent of cancer diagnosis. ConclusionsCancer patients receive care that differs in important ways from patients without cancer. Greater implementation of evidence-based care may reduce HF readmissions, including in cancer patients

Sex-Specific Clinical Outcomes of the PACT-HF Randomized Trial

BACKGROUND: Transitional care may have different effects in males and females hospitalized for heart failure. We assessed the sex-specific effects of a transitional care model on clinical outcomes following hospitalization for heart failure. METHODS: In this stepped-wedge cluster randomized trial of adults hospitalized for heart failure in Ontario, Canada, 10 hospitals were randomized to a group of transitional care services or usual care. Outcomes in this exploratory analysis were composite all-cause readmission, emergency department visit, or death at 6 months; and composite all-cause readmission or emergency department visit at 6 months. Models were adjusted for stepped-wedge design and patient age. RESULTS: Among 2494 adults, mean (SD) age was 77.7 (12.1) years, and 1258 (50.4%) were female. The first composite outcome occurred in 371 (66.3%) versus 433 (64.1%) males (hazard ratio [HR], 1.04 [95% CI, 0.86-1.26]; P=0.67) and in 326 (59.9%) versus 463 (64.8%) females (HR, 0.83 [95% CI, 0.69-1.01]; P=0.06) in the intervention and usual care groups, respectively (P=0.012 for sex interaction). The second composite outcome occurred in 357 (63.8%) versus 417 (61.7%) males (HR, 1.03 [95% CI, 0.85-1.24]; P=0.76) and 314 (57.7%) versus 450 (63.0%) females (HR, 0.81 [95% CI, 0.67-0.99]; P=0.037) in the intervention and usual care groups, respectively (P=0.024 for sex interaction). The sex differences were driven by a reduction in all-cause emergency department visits among females (HR, 0.66 [95% CI, 0.51-0.87]; P=0.003), but not males (HR, 1.10 [95% CI, 0.85-1.43]; P=0.46), receiving the intervention (P<0.001 for sex interaction). CONCLUSIONS: A transitional care model offered a reduction in all-cause emergency department visits among females but not males following hospitalization for heart failure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02112227

Substantial decline in hospital admissions for heart failure accompanied by increased community mortality during COVID-19 pandemic

Objective: We hypothesised that a decline in admissions with heart failure during COVID-19 pandemic would lead to a reciprocal rise in mortality for patients with heart failure in the community. Methods: We used national heart failure audit data to identify 36,974 adults who had a hospital admission with a primary diagnosis of heart failure between February and May in either 2018, 2019 or 2020. Results: Hospital admissions for heart failure in 2018/19 averaged 160/day but were much lower in 2020, reaching a nadir of 64/day on 27th March-2020 (incidence rate ratio:0.40, 95% CI:0.38-0.42). The proportion discharged on guideline-recommended pharmacotherapies was similar in 2018/19 compared to the same period in 2020. Between 1st February-2020 and 31st May-2020, there was a 29% decrease in hospital deaths related to heart failure (IRR:0.71,95% CI:0.67-0.75; estimated decline of 448 deaths), a 31% increase in heart failure deaths at home (IRR:1.31,95% CI:1.24-1.39; estimated excess 539) and a 28% increase in heart failure deaths in care homes and hospices (IRR:1.28,95% CI:1.18-1.40; estimated excess 189). All-cause, in-patient death was similar in the COVID-19 and pre-COVID-19 periods (OR:1.02,95% CI: 0.94–1.10). After hospital discharge, 30-day mortality was higher in 2020 compared to 2018/19 (OR:1.57, 95% CI:1.38–1.78). Conclusion: Compared with the rolling daily average in 2018/19, there was a substantial decline in admissions for heart failure but an increase in deaths from heart failure in the community. Despite similar rates of prescription of guideline-recommended therapy, mortality 30-days from discharge was higher during the COVID-19 pandemic period

Sex differences in the clinical presentation and natural history of dilated cardiomyopathy

Background Biological sex has a diverse impact on the cardiovascular system. Its influence on dilated cardiomyopathy (DCM) remains unresolved. Objectives This study aims to investigate sex-specific differences in DCM presentation, natural history, and prognostic factors. Methods We conducted a prospective observational cohort study of DCM patients assessing baseline characteristics, cardiac magnetic resonance imaging, biomarkers, and genotype. The composite outcome was cardiovascular mortality or major heart failure (HF) events. Results Overall, 206 females and 398 males with DCM were followed for a median of 3.9 years. At baseline, female patients had higher left ventricular ejection fraction, smaller left ventricular volumes, less prevalent mid-wall myocardial fibrosis (23% vs 42%), and lower high-sensitivity cardiac troponin I than males (all P &lt; 0.05) with no difference in time from diagnosis, age at enrollment, N-terminal pro-B-type natriuretic peptide levels, pathogenic DCM genetic variants, myocardial fibrosis extent, or medications used for HF. Despite a more favorable profile, the risk of the primary outcome at 2 years was higher in females than males (8.6% vs 4.4%, adjusted HR: 3.14; 95% CI: 1.55-6.35; P = 0.001). Between 2 and 5 years, the effect of sex as a prognostic modifier attenuated. Age, mid-wall myocardial fibrosis, left ventricular ejection fraction, left atrial volume, N-terminal pro-B-type natriuretic peptide, high-sensitivity cardiac troponin I, left bundle branch block, and NYHA functional class were not sex-specific prognostic factors. Conclusions We identify a novel paradox in prognosis for females with DCM. Female DCM patients have a paradoxical early increase in major HF events despite less prevalent myocardial fibrosis and a milder phenotype at presentation. Future studies should interrogate the mechanistic basis for these sex differences

A review of interventions to improve clinical outcomes following hospitalisation for heart failure

Heart failure (HF) is a leading cause of hospitalisation and death among older adults in high-income countries. HF is often accompanied by comorbid conditions, and patients hospitalised for HF commonly die or are readmitted in the weeks follow- ing hospital discharge. The objectives of this paper are to discuss the burden of HF hospitalisations in healthcare systems and to review strategies that reduce hospitalisations and death in this condition

Social media in heart failure : a mixed methods systematic review

BACKGROUND: Among social media (SoMe) platforms, Twitter and YouTube have gained popularity, facilitating communication between cardiovascular professionals and patients. OBJECTIVE: This mixed-methods systematic review aimed to assess the source profile and content of Twitter and YouTube posts about heart failure (HF). METHODS: We searched PubMed, Embase and Medline using the terms “cardiology,” “social media,” and “heart failure”. We included full-text manuscripts published between January 1, 1999, and April 14, 2019. We searched Twitter and YouTube for posts using the hashtags “#heartfailure”, “#HF”, or “#CHF” on May 15, 2019 and July 6, 2019. We performed a descriptive analysis of the data. RESULTS: Three publications met inclusion criteria, providing 677 tweets for source profile analysis; institutions (54.8%), health professionals (26.6%), and patients (19.4%) were the most common source profiles. The publications provided 1,194 tweets for content analysis: 83.3% were on education for professionals; 33.7% were on patient empowerment; and 22.3% were on research promotion. Our search on Twitter and YouTube generated 2,252 tweets and > 400 videos, of which we analyzed 260 tweets and 260 videos. Sources included institutions (53.5% Twitter, 64.2% YouTube), health professionals (42.3%, 28.5%), and patients (4.2%, 7.3%). Content included education for professionals (39.2% Twitter, 62.3% YouTube), patient empowerment (20.4%, 21.9%), research promotion (28.8%, 13.1%), professional advocacy (5.8%, 2.7%), and research collaboration (5.8%, 0%). CONCLUSION: Twitter and YouTube are platforms for knowledge translation in HF, with contributions from institutions, health professionals, and less commonly, from patients. Both focus largely on education for professionals and less commonly on patient empowerment. Twitter includes more research promotion, research collaboration, and professional advocacy than YouTube