Heart failure

Heart failure readmissions remain challenging


Mortality and length of hospital stay have reduced over the last 15 years for patients with heart failure but persistently high readmission rates demonstrate the complexities of managing elderly patients with comorbidities.

A study of 5,588 patients, enrolled in the nurse-led Management of Cardiac Function (MACARF) program in Northern Sydney and hospitalised for heart failure between 2001 and 2015, found their mean age increased from 74 years to 84 years during the study period.

In particular, the proportion of patients aged over 85 years increased from 10% in 2001–2003 to 58% in 2013–2015.

The prevalence of hypertension, diabetes, chronic kidney disease and aortic stenosis all increased significantly in patients over the 15-year study period.

Infection and arrhythmia were the most common precipitants of hospitalisation in recent years, as ischaemia and AMI have become less common.

Interestingly, the proportion of patients with unknown precipitants has increased from 18% in 2001-2003 to 35% in 2013–2015.

The study, published in Heart, Lung and Circulation, found that the proportion of hospitalised patients with preserved ejection fraction (HFpEF) has increased from 24% to 35%.

Fewer patients required hospital stays longer than seven days in more recent years.

Mortality rates at 30-days, 1-year and 3-years have come down significantly, however readmission rates at 1-year have stubbornly remained above 40%.

Cardiologist and senior author on the paper Professor Geoffrey Tofler, from the Royal North Shore Hospital and University of Sydney, told the limbic that the predominant non-HF causes of readmission reflect the patients’ comorbidities.

However trying to reduce the readmissions from HF causes was also an ongoing challenge.

“Is it related to the fact that more of the elderly patients have heart failure with preserved ejection fraction for which there isn’t a specific medication available?”

“Delays in patients recognising symptoms of worsening heart failure could also lead to admissions that might have been prevented if the symptoms were recognised early enough and acted upon.”

“We also need to learn more about the causes of readmissions in these people and see how we can further improve the two-way links between the community and hospital,” he said.

Professor Tofler said there were certainly opportunities to intervene in the main known precipitants of hospitalisation such as infection, arrhythmia especially atrial fibrillation, and ischaemia.

The ongoing high admission rate also reinforces the need to look into the less common and other unknown causes among the heart failure patients.

“For instance, there is emerging evidence that amyloid plays a more frequent role in heart failure patients,” he said.

The study also showed that medical management was not always optimal, Professor Tofler said.

“For instance, in our MACARF population we saw a reduction in the last two 3-year analysis cycles of the use of beta-blockers and ACE inhibitors in patients with reduced ejection fraction.”

“While the increase in renal impairment adds to the complexity in managing heart failure patients, we need to make sure that we are prescribing the appropriate medications in these people, including newer treatments, and not taking our foot off the accelerator just because of age.”

 

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