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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 52-55

Outcomes related to acute decompensated heart failure admissions: A pilot study


1 Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication20-Jun-2018

Correspondence Address:
Dr. Ajay Kumar Mishra
Department of Internal Medicine, Unit V, Hospital Campus, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_8_18

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  Abstract 

Objectives: In this pilot study we aimed to study the various outcomes related to treatment, morbidity and mortality in patients presenting with acute decompensated heart failure (ADHF). Materials and Methods: In this retrospective, pilot study all patients discharged with the diagnosis of acute decompensated heart failure [ADHF] were included over a span of 6 month of the year 2016. We analysed the details of requirements of oxygen, ventilation, requirements of infusion of diuretics, inotropic agents, duration of stay, cost of treatment and outcomes for these patients. Results: Twenty eight consecutive patients with ADHF were enrolled. Mean age of the patients were 53 years and 64% of these were females. The mean ejection fraction of these patients was 39.4. Most common aetiology of heart failure was ischemia [40%]. In 93% of patients the trigger for acute worsening was identified. Respiratory tract infection was the commonest precipitator {39%]. Only 36% of patients received supplemental oxygen and almost every one received diuretics. The mean duration of hospital stay was 8 days, and the in hospital mortality was 14%. Conclusions: In conclusion this pilot study looked at the outcome details in patients admitted with acute decompensated heart failure. Our patients with ADHF were younger and ha higher prevalence of Ischaemic cardiomyopathy. Most had an identified precipitator, and the most common trigger of heart failure was respiratory infections.

Keywords: Acute, decompensated heart failure, outcome, precipitators


How to cite this article:
Mishra AK, Sugdeb V, Lahiri A, Ramya I. Outcomes related to acute decompensated heart failure admissions: A pilot study. Curr Med Issues 2018;16:52-5

How to cite this URL:
Mishra AK, Sugdeb V, Lahiri A, Ramya I. Outcomes related to acute decompensated heart failure admissions: A pilot study. Curr Med Issues [serial online] 2018 [cited 2019 Dec 7];16:52-5. Available from: http://www.cmijournal.org/text.asp?2018/16/2/52/234836


  Introduction Top


Acute heart failure (AHF) can be classified simply into three subtypes including acute hypertensive heart failure, decompensated heart failure, and cardiogenic shock. Acute decompensated heart failure (ADHF) is defined as the rapid/gradual onset of, or change in symptoms and signs of congestion in a patient with preexisting heart failure.[1] In developed countries, heart failure accounts for 1%–3% of all hospital admission. While more than a million AHF admissions are reported, readmission rates are >30% among such patients with worsening risk of mortality following each admission. Heart failure in India has increased by hundredfold from 1990 to 2013. Risk factor models in India have estimated around 1.3–4.6 millions of people with HF.[2],[3] In the background of scanty literature, available Indian studies on ADHF have looked into outcomes such as death and rehospitalization. In this pilot study, we aimed to study the various outcomes related to treatment, along with morbidity and mortality.


  Methodology Top


In this retrospective, pilot study, all patients discharged with the diagnosis of ADHF were included from the database. Patients were included from a single medical unit over a span of 6 months of the year 2016. All patients presenting with acute or gradual worsening of the symptoms and signs of failure requiring admissions into emergency department for urgent medical care were defined to have ADHF. Details of demography, clinical parameters, metabolic parameters, and treatment were obtained. We also included the details of requirements of oxygen, ventilation, requirements of infusion of diuretics, inotropic agents, duration of stay, cost of treatment, and outcomes for these patients. Statistical analysis included reporting means for continuous variables and percentages for categorical variables.


  Results Top


In this study, 28 patients with ADHF were enrolled over the time period of 6 months. The mean ages of patients were 53. There was a female predominance with the male-to-female ratio being 1:1.7. Comorbidities such as diabetes and hypertension were present in 46% of patients as shown in [Table 1]. Nearly 13 (46%) of patients had anemia at the time of presentation; however only 2 (0.07%) patients had a hemoglobin of <8 requiring transfusion. Echocardiographic details were available in 78% (22) of patients. Among these, reduced ejection fractions (<50%) were present in 18 (82%) and 4 (18%) patients had preserved ejection fraction. The mean ejection fraction was 39.4% (21–58). Most common cause of heart failure was ischemia in 11 (40%), followed by hypertensive heart failure in 4 (14%), dilated cardiomyopathy in 4 (14%), valvular heart disease in 3 (10%), rhythm abnormality in 3 (10%), and myocarditis in 3 (10%), respectively. Among all the patients, 28% (8) had pulmonary artery hypertension at the time of admission. Risk factors for diabetes and hypertension were present in 43% (13) of patients. At the time of admission, precipitators for worsening of cardiac failure were identified in 93% (26) of patients. As shown in [Figure 1], the most common precipitator was an infection in 11 (39%) followed by myocardial infarction in 9 (32%). At the time of admission, 11 (39%) of patients had a systolic blood pressure of >140 mmHg, 10 (36%) had a SBP between 90 and 139, and 7 patients (25%) had a SBP of <90 mmHg.
Table 1: Base line characteristics of patients with acute decompensated heart failure

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Figure 1: The precipitators of acute decompensated heart failure.

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Following admission, 10 (36%) of patients required oxygen supplementation. Among all the patients, 10 (36%) required supportive ventilation, of which 8 (29%) required noninvasive ventilation as compared to 2 (7%) requiring invasive mechanical ventilation. Almost everyone (26 [93%]) required diuretics only and 10 (36%) were managed with continuous infusion of diuretic. Requirements of inotropes were needed for 14 (50%) as compared to vasodilators in 3 (11%) patients. The average duration of inpatient stay was 8 days and the cost was 63,000 rupees (1000$). Posttreatment 22 (78%) patients were discharged in a stable condition. Poor outcomes in the form of discharge against medical advice in a moribund condition and mortality occurred in 2 (7%) and 4 (14%) of patients.


  Discussion Top


This pilot study conducted in an internal medicine department of a tertiary care center provides initial data on management details and outcomes in patient with ADHF. The Trivandrum heart failure registry (THFR) and Acute Failure Registry Study (AFAR) have studied in detail about the clinical presentation, comorbidities, etiologies, and guideline-based treatment details in India.[1],[4] Alike the previous two studies, our patients were also 10 years younger at the time of presentation [Table 2] as compared to the Western population.[5] The most common etiology of heart failure in our study was ischemic heart disease which was similar to the previous Western and Indian studies. The mean ejection fraction in our patients was equivalent to OPTIMIZE-HF (39%).
Table 2: Comparison of our patients with optimize, Trivandrum Heart Failure Registry and Acute Failure Registry Study

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In our study, only 36% (10) patients received supplemental oxygen. In patients with heart failure, routine use of oxygen is contraindicated, and supplemental oxygen should only be used for hypoxic patients with SaO2 of <90.[6] As hyperoxia is known to cause harm by vasoconstriction and endothelial reactive oxygen species production which leads to further cardiac stunning and injury.[7] Almost 36% (10) of patients were managed with mechanical ventilation only and 7% (2) required invasive ventilation which was almost similar to 5% patients in three interventions in cardiogenic pulmonary oedema (3 CPO) study.[8] Authors suggest that most health care centers equipped with the facility of noninvasive ventilation can be able to provide optimal cardiac failure care to most patients. 3 CPO trial intervention details should be adhered to for optimal outcome.



Triggers for AHF admissions were identified in 93% of patients. Similar to OPTIMIZE HF database, the most common etiology identified during the time of admission was respiratory infections, acute coronary syndrome, and arrhythmia. The other important precipitators of these events are uncontrolled hypertension, worsening renal function, nonadherence to diet, and medications.[5] The two initial and important steps in preventing these triggers should be (1) control of acute coronary syndrome risk factors and (2) optimization treatment and vaccinations for respiratory infections in patients with heart failure.[9],[10],[11] At admission, most patients were treated with loop diuretics. Almost 36% of patients also were treated with diuretics infusion. Although Diuretic Optimization Strategies Evaluation trial and a meta-analysis of 10 randomized clinical trials showed no difference in improvements in failure symptoms and renal function between the patients receiving diuretic infusion as compared to bolus diuretic doses, still the optimal dose, frequency, and method of diuretics usage continue to be based on clinicians' initial clinical judgment and patients response to treatment.[12],[13]

Mean duration of in-hospital stay in our patients was 8 days as compared to the median duration of 6 days in THFR. The average cost of in-hospital treatment and stay was 63,000 rupees. Mortality was higher as compared to THFR and OPTIMIZE-HF study as shown in [Table 2]. The limitations of this descriptive pilot study are retrospective nature of data from a single medical unit, small sample size, along with a lack of validated details on functional status, and lack of availability of follow-up details.

In conclusion, this pilot study looked at the outcome details in patients admitted with ADHF. Our patients with ADHF were younger and had a higher prevalence of ischemic cardiomyopathy. Most had an identified precipitator, and the most common trigger of heart failure was respiratory infections. Oxygen was not used for all patients; diuretics were the most common drugs used. Duration of in-hospital stay and mortality was higher as compared to previous studies. Future prospective studies from India could look into the role of optimized evidence-based medications, the role of newer cardiac failure agents, and long-term details on the financial burden disability, morbidity, and mortality.

Financial support and sponsorship

This study was financially self-funded.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Seth S, Khanal S, Ramakrishnan S, Gupta N, Bahl VK. Epidemiology of acute decompensated heart failure in India: The AFAR study (Acute failure registry study). J Pract Cardiovasc Sci 2015;1:35-8.  Back to cited text no. 1
  [Full text]  
2.
Huffman MD, Prabhakaran D. Heart failure: Epidemiology and prevention in India. Natl Med J India 2010;23:283-8.  Back to cited text no. 2
[PUBMED]    
3.
Pillai HS, Ganapathi S. Heart failure in South Asia. Curr Cardiol Rev 2013;9:102-11.  Back to cited text no. 3
[PUBMED]    
4.
Harikrishnan S, Sanjay G, Anees T, Viswanathan S, Vijayaraghavan G, Bahuleyan CG, et al. Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: The Trivandrum Heart Failure Registry. Eur J Heart Fail 2015;17:794-800.  Back to cited text no. 4
[PUBMED]    
5.
Fonarow GC, Abraham WT, Albert NM, Gattis Stough W, Gheorghiade M, Greenberg BH, et al. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: Results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Arch Intern Med 2007;167:1493-502.  Back to cited text no. 5
[PUBMED]    
6.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the Special Contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129-200.  Back to cited text no. 6
    
7.
Sepehrvand N, Ezekowitz JA. Oxygen therapy in patients with acute heart failure: Friend or foe? JACC Heart Fail 2016;4:783-90.  Back to cited text no. 7
[PUBMED]    
8.
Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med 2008;359:142-51.  Back to cited text no. 8
[PUBMED]    
9.
Bhatt AS, DeVore AD, Hernandez AF, Mentz RJ. Can vaccinations improve heart failure outcomes?: Contemporary data and future directions. JACC Heart Fail 2017;5:194-203.  Back to cited text no. 9
[PUBMED]    
10.
Kadoglou NP, Bracke F, Simmers T, Tsiodras S, Parissis J. Influenza infection and heart failure-vaccination may change heart failure prognosis? Heart Fail Rev 2017;22:329-36.  Back to cited text no. 10
    
11.
Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: Results from the Kerala ACS registry. Eur Heart J 2013;34:121-9.  Back to cited text no. 11
[PUBMED]    
12.
Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364:797-805.  Back to cited text no. 12
[PUBMED]    
13.
Wu MY, Chang NC, Su CL, Hsu YH, Chen TW, Lin YF, et al. Loop diuretic strategies in patients with acute decompensated heart failure: A meta-analysis of randomized controlled trials. J Crit Care 2014;29:2-9.  Back to cited text no. 13
[PUBMED]    


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