Abstract TP300: Re-admissions in Patients With First Onset of Stroke - Looking Beyond Organ Systems

Background: Patients who suffer from a stroke are susceptible to multiple complications, with readmission rates ranging from 20-40% per year, and approximately 25% of readmissions occurring within the first month 1 . Major reasons contributing to readmissions include recurrent stroke (24%), infection (12%), chest pain or myocardial infarction (10%), worsening of stroke symptoms (7%), arrhythmias (7%), and congestive heart failure (3%) 2 . However, additional potentially reversible risk factors have not been extensively studied. Methods: This retrospective study was conducted at a tertiary hospital in Singapore and included 1283 patients who were admitted for stroke between Jan 2014 and Oct 2015. All patients who had previous history of stroke or died on initial presentation were excluded from the study, leaving 957 patients with first stroke presentation. The dates and diagnoses of readmissions in the first 90 days were collected. Elective admissions or readmissions due to recurrent strokes or coronary syndromes were excluded to focus on readmissions due to infections, medication side effects, falls, or care coordination issues. Results: Out of 957 patients, 129 (13.4%) were readmitted within 90 days. 98 (10.2%) were readmitted once in 90 days, while 31 (3.2%) were readmitted multiple (2-7) times. The single readmission group showed a bi-modal distribution with 35.7% of readmissions occurring in the first 15 days, 15.3% in 15-30 days, 34.7% in 30-60 days, and 24.5% in 60-90 days after discharge. In the single readmission group, 36.7% of patients were readmitted for infections (15.3% were urinary tract infections, 21.4% were chest infections), 12.2% were admitted for congestive heart failure symptoms, and 17.3% were admitted for falls or care coordination issues. A majority (59%) of readmitted patients were over the age of 70. 24% of the patients had a middle cerebral artery (MCA) stroke, and 34% had a decrease in function of activities of daily living on discharge. Conclusion: This study helps to highlight high risk groups for readmissions i.e. patients over the age of 70 years, reduction in function on discharge, and patients with MCA strokes, suitable for targeted interventions in order to reduce rate of readmissions in patients with first stroke.

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Cognitive dysfunction in congestive heart failure: transcranial Doppler evidence of microembolic etiology

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2006000200007 ◽

2006 ◽

Vol 64 (2a) ◽

pp. 207-210 ◽

Cited By ~ 20

Author(s):

Pedro A.P. Jesus ◽

Rodrigo M. Vieira-de-Melo ◽

Francisco J.F.B. Reis ◽

Leila C. Viana ◽

Amanda Lacerda ◽

...

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Transcranial Doppler ◽

Pulsatility Index ◽

Mmse Score ◽

Significant Proportion ◽

Previous History ◽

Cognitive Symptoms ◽

Mean Flow ◽

Cerebrovascular Resistance

Cognitive symptoms are common in patients with congestive heart failure (CHF) and are usually attributed to low cerebral blood flow. In the present study, we aimed to evaluate global cognitive function (Mini Mental State Exam MMSE) in relation to both cardiac function (evaluated by echocardiogram) and cerebrovascular hemodynamics (evaluated by transcranial Doppler TCD) in CHF patients. In 83 patients studied, no correlation was found between echocardiographic parameters and MMSE scores. In contrast, a significant correlation was found between right middle cerebral artery (RMCA) mean flow velocity and MMSE score (r=0.231 p=0.039), as well as between RMCA pulsatility index and MMSE score (r s= -0.292 p=0.015). After excluding patients with a previous history of stroke, only RMCA pulsatility index correlated with MMSE score (r s=-0,314 p=0,007). The relationship between high cerebrovascular resistance and worse cognitive scores suggest that microembolism may be responsible for a significant proportion of cognitive symptoms in CHF patients.

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Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age

Clinical Medicine Insights Cardiology ◽

10.1177/1179546818809358 ◽

2018 ◽

Vol 12 ◽

pp. 117954681880935 ◽

Cited By ~ 8

Author(s):

Pupalan Iyngkaran ◽

Danny Liew ◽

Christopher Neil ◽

Andrea Driscoll ◽

Thomas H Marwick ◽

...

Keyword(s):

Heart Failure ◽

New York ◽

Congestive Heart Failure ◽

Heart Association ◽

Multidisciplinary Care ◽

The Elderly ◽

Tertiary Hospital ◽

Chronic Obstructive ◽

Common Denominator ◽

Chronic Renal Impairment

This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.

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Changing Strategies in the Management of Chronic Congestive Heart Failure

DICP ◽

10.1177/106002809102501214 ◽

1991 ◽

Vol 25 (12) ◽

pp. 1349-1354 ◽

Cited By ~ 1

Author(s):

Daniel E. Hilleman ◽

Syed M. Mohiuddin

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Mortality Rate ◽

Heart Transplantation ◽

Nyha Class ◽

Class Ii ◽

Left Ventricular ◽

Fixed Dose ◽

Chronic Congestive Heart Failure ◽

Organ Systems

Recent studies have more clearly defined the role of drug therapy in patients with chronic congestive heart failure (CHF). Treatment of patients with asymptomatic left ventricular dysfunction (New York Heart Association [NYHA] class I) cannot be recommended at this time. The benefit of prophylactic treatment with angiotensin-converting enzyme inhibitors (ACEIs) or vasodilators in patients at high risk for developing symptomatic CHF is currently being evaluated. Treatment of patients with symptomatic CHF (NYHA class II-IV) should be initiated with a combination of a diuretic, digoxin, and an ACEI. This combination has been shown to reduce the mortality rate in patients with NYHA class II-IV CHF. Patients who remain symptomatic despite treatment with this combination may benefit from the addition of the direct-acting, nonspecific vasodilators—hydralazine and a nitrate. The addition of the nonspecific vasodilators to an ACEI has not been tested in controlled trials. In patients who remain symptomatic despite treatment with diuretics, digoxin, ACEIs, and nonspecific vasodilators, treatment options are not clear. The use of beta-agonists, phosphodiesterase inhibitors, and intermittent fixed-dose, fixed-interval dobutamine should be avoided as these agents are associated with a high mortality rate. Heart transplantation should be considered early in the course of CHF to allow for preservation of other vital organ systems. Unfortunately, heart transplantation is available to only a very small minority of potential transplant candidates.

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Characteristics of Saudi patients with congestive heart failure and adherence to management guidelines in a tertiary hospital in Riyadh

Annals of Saudi Medicine ◽

10.5144/0256-4947.2012.583 ◽

2012 ◽

Vol 32 (6) ◽

pp. 583-587 ◽

Cited By ~ 1

Author(s):

Mohammad Alqahtani ◽

Thari Alanazi ◽

Salih Binsalih ◽

Naji Aljohani ◽

Mohammed Alshammari ◽

...

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Tertiary Hospital ◽

Management Guidelines ◽

Saudi Patients

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Transition Networks in a Cohort of Patients with Congestive Heart Failure

Applied Clinical Informatics ◽

10.4338/aci-2015-02-ra-0021 ◽

2015 ◽

Vol 06 (03) ◽

pp. 548-564 ◽

Cited By ~ 20

Author(s):

B. M. Sheehan ◽

K. M. Carley ◽

P. D. Stetson ◽

J. A. Merrill

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Network Analysis ◽

Service Delivery ◽

Care Coordination ◽

Hospital Admissions ◽

Health Care Service ◽

World Health ◽

High Morbidity ◽

Transition Networks

SummaryBackground: Unnecessary hospital readmissions are one source of escalating costs that may be reduced through improved care coordination, but how best to design and evaluate coordination programs is poorly understood. Measuring patient flow between service visits could support decisions for coordinating care, particularly for conditions such as congestive heart failure (CHF) which have high morbidity, costs, and hospital readmission rates.Objective: To determine the feasibility of using network analysis to explore patterns of service delivery for patients with CHF in the context of readmissions.Methods: A retrospective cohort study used de-identified records for patients 18 years with an ICD-9 diagnosis code 428.0–428.9, and service visits between July 2011 and June 2012. Patients were stratified by admission outcome. Traditional and novel network analysis techniques were applied to characterize care patterns.Results: Patients transitioned between services in different order and frequency depending on admission status. Patient-to-service CoUsage networks were diffuse suggesting unstructured flow of patients with no obvious coordination hubs. In service-to-service Transition networks a specialty heart failure service was on the care path to the most other services for never admitted patients, evidence of how specialist care may prevent hospital admissions for some patients. For patients admitted once, transitions expanded for a clinic-based internal medicine service which clinical experts identified as a Patient Centered Medical Home implemented in the first month for which we obtained data.Conclusions: We detected valid patterns consistent with a targeted care initiative, which experts could understand and explain, suggesting the method has utility for understanding coordination. The analysis revealed strong but complex patterns that could not be demonstrated using traditional linear methods alone. Network analysis supports measurement of real world health care service delivery, shows how transitions vary between services based on outcome, and with further development has potential to inform coordination strategies.Citation: Merrill JA, Sheehan BM, Carley KM, Stetson PD. Transition networks in a cohort of patients with congestive heart failure: a novel application of informatics methods to inform care coordination. Appl Clin Inform 2015; 6: 548–564http://dx.doi.org/10.4338/ACI-2015-02-RA-0021

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Primary systemic amyloidosis: multivariate analysis for prognostic factors in 168 cases

Blood ◽

10.1182/blood.v68.1.220.220 ◽

1986 ◽

Vol 68 (1) ◽

pp. 220-224 ◽

Cited By ~ 142

Author(s):

RA Kyle ◽

PR Greipp ◽

WM O'Fallon

Keyword(s):

Heart Failure ◽

Multiple Myeloma ◽

Congestive Heart Failure ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Risk Groups ◽

Systemic Amyloidosis ◽

First Year ◽

Hazards Model ◽

Major Factors

Abstract One hundred sixty-eight patients with primary systemic amyloidosis (AL) were identified. Median survival after diagnosis was 12 months and ranged from 4 months for patients presenting with congestive heart failure to 50 months for those presenting with peripheral neuropathy only. Utilizing the proportional-hazards model in a stepwise multivariate fashion to evaluate the simultaneous influence of putative risk factors as of diagnosis revealed that congestive heart failure, urine light chain, hepatomegaly, and multiple myeloma were the major factors adversely affecting survival during the first year after diagnosis. Serum creatinine, multiple myeloma, orthostatic hypotension, and monoclonal serum protein were the most important variables adversely affecting survival for patients surviving 1 year. These models were used to categorize patients according to the variables in the models into low-, moderate-, and high-risk groups for the first year after diagnosis and separately for subsequent years. The influence of these variables on survival is important in stratification of patients randomized to prospective clinical trials.

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Cardiotoxicity during Chemotherapy for Advanced Gastroenteric Tumors

Tumori Journal ◽

10.1177/030089168707300407 ◽

1987 ◽

Vol 73 (4) ◽

pp. 359-361 ◽

Cited By ~ 5

Author(s):

Alberto Raina ◽

Furio Ferrante ◽

Antonietta Bisol ◽

Giancarla Fiori ◽

Marco Galeone

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Angina Pectoris ◽

Drug Interactions ◽

Cardiac Disease ◽

Previous History ◽

Cytotoxic Drugs ◽

Dilatative Cardiomyopathy ◽

Associated Symptoms ◽

History Of

The authors report two cases of patients with advanced gastroenteric carcinoma, which developed different cardiotoxicity patterns after the administration of cytotoxic drugs. The firsts patient showed a picture of dilatative cardiomyopathy with associated symptoms of angina pectoris and congestive heart failure; the second patient presented a cardiac arrhythmia after several administrations of S-fluorouracil. The possible mechanisms of these toxic effects, as well as the drug interactions are briefly discussed. Cardiotoxicity of cytotoxic drugs should be considered by oncologists even in patients with no previous history of cardiac disease.

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