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Longer-than-average length of stay in acute heart failure

Determinants and outcomes

Überdurchschnittliche Verweildauer bei akuter Herzinsuffizienz

Einflussfaktoren und Ergebnisse

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Abstract

Background

Increased length of stay (LOS) during acute heart failure (HF) hospitalization is associated with readmission and mortality.

Methods

The ESCAPE trial data were utilized to identify determinants and post-discharge outcomes of patients with acute systolic HF requiring longer-than-average LOS (≥7 days). The study endpoints were 6‑month all-cause mortality, all-cause rehospitalization, and the composite endpoint of death, cardiac rehospitalization, and cardiac transplant.

Results

Among the 424 patients with recorded LOS, 216 (50.9%) and 208 (49.1%) had LOS ≥ or <7 days, respectively. Independent determinants of longer-than-average LOS included older age (OR per 10-year increase: 1.759, 95% CI: 1.120–2.763, p = 0.014), higher blood urea nitrogen (OR per 5 mg/dl increase: 1.202, 95% CI: 1.024–1.410, p = 0.024), greater inferior vena cava diameter (OR per 1 cm increase: 2.453, 95% CI: 1.175–5.121, p = 0.017), and lower sodium (OR per 4 mmol/l increase: 0.494, 95% CI: 0.268–0.911, p = 0.024). We found a significant correlation between right-sided failure (right atrial pressure) and LOS (r = 0.229, p = 0.001) but not left-sided failure (pulmonary capillary wedge pressure, r = 0.099, p = 0.177). Patients with longer-than-average LOS had a significantly higher mortality (25.9% vs. 12%, univariate OR: 2.562, 95% CI: 1.528–4.296, p &lt; 0.001), higher all-cause rehospitalization (63% vs. 53.4%, univariate OR: 1.486, 95% CI: 1.008–2.190, p = 0.046) and higher frequency of the composite endpoint of death, cardiac rehospitalization, and cardiac transplant (61.6% vs. 45.2%, univariate OR: 1.943, 95% CI: 1.320–2.862, p = 0.001) compared with an LOS of <7 days. Cox proportional hazard analysis showed that a longer-than-average LOS was an independent predictor of 6‑month all-cause mortality (HR: 1.930, 95% CI: 1.112–3.350, p = 0.019).

Conclusion

In acute HF, right ventricular failure and renal dysfunction predict longer-than-average LOS, which is a proxy for more severe HF and is associated with worse postdischarge outcomes.

Zusammenfassung

Hintergrund

Die Verweildauer im Krankenhaus („length of stay“, LOS) bei akuter Herzinsuffizienz ist mit Rehospitalisierung und Mortalität verknüpft.

Methoden

Anhand der Daten der ESCAPE-Studie wurden Einflussfaktoren und Ergebnisse nach Entlassung von Patienten ermittelt, bei denen eine überdurchschnittlich lange LOS (≥7 Tage) wegen akuter systolischer HF erforderlich war. Studienendpunkte waren die 6‑Monats-Gesamtmortalität und der zusammengesetzte Endpunkt aus Tod, kardial bedingter Wiederaufnahme und Herztransplantation.

Ergebnisse

Von den 424 Patienten mit dokumentierter LOS betrug diese bei 216 (50,9%) ≥7 bzw. bei 208 (49,1%) <7 Tage. Zu den unabhängigen Faktoren einer überdurchschnittlichen LOS gehörten höheres Alter (Odds Ratio (OR) pro 10-Jahres-Anstieg: 1,759; 95%-Konfidenzintervall (95%-KI): 1,120–2,763; p = 0,014), höhere Blut-Harnstoff-Stickstoff-Werte (OR pro Anstieg um 5 mg/dl: 1,202; 95%-KI: 1,024–1,410; p = 0,024), größerer Durchmesser der V. cava inferior (OR pro Anstieg um 1 cm: 2,453; 95%-KI: 1,175–5,121; p = 0,017) und niedrigere Na-Werte (OR pro Anstieg um 4 mmol/l: 0,494; 95%-KI: 0,268–0,911; p = 0,024). Es stellte sich eine signifikante Korrelation zwischen Rechtherzinsuffizienz (rechter Vorhofdruck) und LOS heraus (r = 0,229; p = 0,001), nicht aber für Linksherzinsuffizienz (pulmonalkapillärer Verschlussdruck, r = 0,099; p = 0,177). Bei Patienten mit überdurchschnittlicher LOS fand sich eine signifikant höhere Mortalität (25,9% vs. 12%, univariate OR: 2,562, 95%-KI: 1,528–4,296, p &lt; 0,001), höhere Rehospitalisierung jeglicher Ursache (63% vs. 53,4%, univariate OR: 1,486, 95%-KI: 1,008–2,190, p = 0,046) und höhere Häufigkeit des zusammengesetzten Endpunkts aus Tod, kardial bedingter Wiederaufnahme und Herztransplantation (61,6% vs. 45,2%; univariate OR: 1,943; 95%-KI: 1,320–2,862; p = 0,001) gegenüber einer LOS <7 Tage. Die Proportional-Hazard-Analyse nach Cox zeigte, dass eine überdurchschnittliche LOS einen unabhängigen Prädiktor der 6‑Monats-Gesamtmortalität darstellte (Hazard Ratio: 1,930; 95%-KI: 1,112–3,350; p = 0,019).

Schlussfolgerung

Bei akuter Herzinsuffizienz dienen Zeichen der Rechtsherzinsuffizienz und der Nierenfunktionsstörung als Prädiktor einer überdurchschnittlichen LOS. Letztere stellt einen Ersatzparameter für eine schwerere Herzinsuffizienz dar und geht mit schlechteren Ergebnissen nach Entlassung aus dem Krankenhaus einher.

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Acknowledgements

The ESCAPE trial was conducted and supported by the NHLBI in collaboration with the ESCAPE study investigators. This article was prepared using a limited access dataset obtained from the NHLBI and does not necessarily reflect the opinions or views of the ESCAPE trial investigators or the NHLBI.

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Authors and Affiliations

  1. Internal Medicine Department, Mercy Medical Center, Clinton, IA, USA

    H. R. Omar MD

  2. Division of Cardiovascular Medicine, Linda and Jack Gill Heart Institute, University of Kentucky, Lexington, KY, USA

    M. Guglin MD

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Correspondence to H. R. Omar MD.

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H.R. Omar and M. Guglin declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Omar, H.R., Guglin, M. Longer-than-average length of stay in acute heart failure. Herz 43, 131–139 (2018). https://doi.org/10.1007/s00059-016-4532-3

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  • DOI: https://doi.org/10.1007/s00059-016-4532-3

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