David Brill
The factors that precipitate hospitalization for heart failure (HF) are independent predictors of clinical outcomes, a large multicenter study from the US has found.
HF patients who were hospitalized with pneumonia, worsening renal function or ischemia had the highest in-hospital mortality, whereas those with uncontrolled hypertension had the lowest. Ischemia and worsening renal function were also most strongly associated with mortality following discharge.
“Identifying these precipitating factors can be helpful for clinicians and give us targets for therapy addressing some of these precipitating factors, which are preventable,” said Professor Gregg Fonarow, principal investigator for the study and associate chief of the division of cardiology at the University of California, Los Angeles.
“This can help improve clinical outcomes, improve care and avoid future hospitalizations, and be important in optimizing the management of this high-risk, high-morbidity and high-mortality patient population.”
The study, part of the ongoing Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF), included data on 48,612 patients from 259 US hospitals with 60 to 90 days of follow-up for each case. Almost two-thirds of patients (61.3 percent) were identified as having at least one factor that had led to hospitalization. [Arch Intern Med 2008 Apr 28;168(8):847-54]
The risk-adjusted odds ratios (ORs) for in-hospital mortality were 1.6 for patients hospitalized
with pneumonia, 1.48 for worsening renal function, 1.2 for ischemia, and .74 for uncontrolled hypertension – a factor which was also linked to a lower overall risk of death or rehospitalization following discharge (hazard ratio .71). ORs for mortality during followup were 1.52 for ischemia and 1.46 for worsening renal function.
In light of these findings, Fonarow advised hospital doctors who are treating HF patients to read through the history, determine which factors may have contributed to their worsening in symptoms and take steps to rectify them.
Dr. Kenneth Ng from the Novena Heart Centre in Singapore agreed that identifying and addressing precipitating factors is important for preventing a recurrence of hospitalization for HF.
“In (Singapore’s) National Healthcare Group hospitals we have a built-in protocol to vaccinate
all our HF patients against influenza and pneumonia,” Ng said. He added that: “every effort
should be made to monitor renal function closely, especially when starting and titrating angiotensinconverting enzyme inhibitors and angiotensin receptor blockers”.
Ng admitted, however, that he was “a little disappointed” with the modest nature of the study’s results – when the researchers compared all patients with one or more precipitating factors against those with none, the adjusted OR for inhospital mortality was .88 (95 percent
CI .78 – 1.00) with a borderline P-value of .046. There was no significant difference in follow-up mortality when comparing these patient groups.
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