Abstract Background The pathogenic role of ischemic heart disease (IHD) in heart failure is well known. However, little is known about the global differences in the prognostic significance and treatment patterns of IHD in acute heart failure (AHF). Methods We prospectively enrolled 18,553 patients with AHF from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic etiology of the AHF event or coronary revascularization were classified as IHD. Differences in clinical characteristics, treatment and outcome were analyzed. Results Compared to 9,344 (50%) patients without IHD, the 9,189 (50%) patients with IHD were older, more often had a left ventricular ejection fraction [LVEF] <40%, (HFrEF) and decompensated chronic HF (DCHF) and had a greater comorbidity burden. Despite patients from lower-income countries having a higher prevalence of IHD (55% vs. 45% in high-income countries), only 27% of patients with IHD from low-income countries were treated with medicines commonly prescribed for HF (Figure A) compared to 16% of patients with IHD from high income countries. After correction for clinical confounders and medication use, patients with IHD had a shorter “door-to-nitrates and -diuretics time” and worse 1-year mortality (hazard ratio: 1.18, 95% CI: 1.09, 1.27, Figure B) irrespective of geographic region (Pinteraction >0.1). We found a significant interaction for prognosis (Pinteraction <0.001) between IHD and HF diagnosis (DCHF vs. new-onset HF) as well as HF subtype (HFrEF vs. HF with preserved ejection fraction) respectively, such that IHD conveyed worse outcomes in patients with new-onset HF and HFrEF respectively in all world regions. Conclusion In this large global contemporary cohort of patients with AHF, IHD was more common in patients from low income countries, conveyed worse 1-year mortality, particularly in patients with new onset HF and patients with HFrEF. Despite worse outcomes, patients in regions with the greatest burden of IHD were more often undertreated. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Novartis

IntroductionWe report on a novel tandem liquid chromatography mass spectrometry (LC/MS/MS) method for the simultaneous bioanalytical assessment of blood levels for multiple commonly prescribed medications, including angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB). Despite morbidity and mortality benefits of ACEI/ARBs, these medications may cause transient rise in creatinine and occasionally contribute to hypotension, which in turn may result in acute kidney injury (AKI). Previous studies of AKI in the setting of ACEI/ARBs have not assessed medication levels.HypothesisWe hypothesized ACEI/ARB plasma levels in/above reference range for patients with AHF treated by intravenous (IV) diuretics would be associated with increased risk of in-hospital AKI compared to undetectable/low ACEI/ARB plasma levels.MethodsFrom June 2016 to June 2017, adults with AHF were approached for consent. Patients were excluded for: 1) no outpatient ACEI/ARB, 2) systolic blood pressure <90 mm Hg, 3) IV diuretic before enrollment, 4) allergy to furosemide or bumetanide, or 5) any dialysis. Patients were given an initial IV dose of diuretic (2x their daily dose) and received standard clinical care during hospitalization. LC/MS/MS assessed medication plasma levels at ED presentation, before AHF therapy. Standardized plasma concentrations for each medication were computed using the median published reference range. AKI was defined as a rise in creatinine at 48 hours (or at hospital discharge, if unavailable) of ≥0.3 mg/dL or ≥1.5x baseline.ResultsMean age for the 37 patients was 65.9 years (sd 14.6), 20 (54.0%) were female, 11 (29.7%) were African American, 10 (32.3%) had an ejection fraction <40%, and 11 (29.8%) did not have detectible ACEI/ARB levels. Of the 5 (13.5%) patients who developed in-hospital AKI, 4 had medications in/above reference range. ACEI/ARB levels were higher for patients with AKI (Figure), and ACEI/ARB levels in/above reference range at the time of ED presentation were associated with an in-hospital rise in creatinine (beta 0.22, 95% confidence interval 0.02-0.42, P=0.03, adjusted for age, sex, and race).ConclusionsPatients with AHF may be more likely to develop AKI in the hospital if they have ACEI/ARB blood levels in/above reference range at ED presentation. Bioanalytical assessment of ACEI/ARB levels may prove useful for guiding in-hospital medical therapy for AHF.

Background: Barriers in heart failure self-care contribute to heart failure hospitalizations, but geographic differences have not been well-studied. We aimed to compare self-care barriers in heart failure patients managed at tertiary centers in an Eastern (Singapore) versus a Western (USA) nation. Methods: Acute heart failure patients were prospectively assessed with a standardized instrument comprising of 47 distinct self-care barriers. The multi-equation generalized structural equation model was used to evaluate for geographic differences in barriers experienced, and association of barriers with outcomes. Results: Patient-related factors accounted for six out of 10 most prevalent self-care barriers among the 90 patients, with a median number of 11 barriers reported per patient. The Western patients reported a higher level of barriers when compared with their Eastern counterparts (median (interquartile range) 15 (9-24) versus 9 (4-16), p=0.001), after adjusting for demographics and co-morbidities. Many of these differences could be explained by geographic differences between the countries. There was no significant difference identified in all-cause mortality (19.4% versus 10.2%) and heart failure re-hospitalization (41.9% versus 45.8%) at six months between the groups. Conclusions: Self-care barriers are highly prevalent among acute heart failure patients, and differ substantially between East and West, but were not associated with geographic differences in outcomes.

Odontogenic infections present commonly in the emergency department (ED) setting. The combination of penicillin (PCN) and metronidazole effectively treats these infections but patient-reported PCN allergy often requires substitution with clindamycin, a more expensive medication associated with potentially serious side effects. Previously, we reported that patients presenting to the ED with a history of PCN allergy had a 91.3% false-positive rate of self-reported PCN allergy confirmed by PCN skin testing. Although PCN skin testing was demonstrated to be feasible in the ED setting it was unclear whether this procedure would be cost-effective to use routinely. The objective of this study was to determine the cost-effectiveness of ED-based PCN skin testing in patients with odontogenic infections who reported a PCN allergy.

Rapid, accurate emergency department (ED) prediction of acute decompensated heart failure (ADHF) is problematic. Natriuretic peptides have been shown to be helpful to exclude ADHF, but are not diagnostic for ADHF until they are elevated significantly (>400 pg/ml). This leaves an indeterminate zone (100-400 pg/ml) where BNP levels are problematic. The Audicor S3, available at the bedside in the ED, is highly specific for ADHF. We sought to determine the impact of an Audicor S3 on treating physician confidence level and the diagnostic accuracy of an Audicor S3 in the BNP indeterminate zone.

Rapid, accurate emergency department (ED) prediction of acute decompensated heart failure (ADHF) is problematic. Many patients present with undifferentiated dyspnea and often have other confounding pulmonary co-morbidities. The S3 has been shown to be highly specific for ADHF. We sought to compare the bedside test characteristics of an S3 detected electronically with that detected by emergency physicians for prediction of ADHF.

The presence of congestive heart failure (CHF) has been associated with treatment disparities and worse outcomes in patients with ST-segment elevation myocardial infarction, but the incidence and effect of CHF in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACSs) has not been well characterized. We evaluated 45,744 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) who were treated at 424 hospitals in the CRUSADE Quality Improvement Initiative between March 2000 and March 2003. Treatment patterns and in-hospital outcomes in patients with signs of CHF on presentation and those who developed in-hospital CHF were compared with those in patients without CHF. In total, 10,398 patients (22.7%) had signs of CHF on presentation, and 1,664 patients (3.6%) later developed in-hospital CHF. Compared with patients without CHF, early (< 24 hours from presentation) medications and invasive cardiac procedures were used less often in patients with signs of CHF on presentation. Likewise, patients with in-hospital CHF were less likely than those without CHF to receive acute antiplatelet agents and undergo cardiac catheterization but more likely to receive acute beta blockers, angiotensin-converting enzyme inhibitors, and heparin and to undergo coronary artery bypass grafting. Adjusted mortality was higher in patients with signs of CHF on presentation (odds ratio 2.64, 95% confidence interval 2.31 to 3.01) and those with in-hospital CHF (odds ratio 4.93, 95% confidence interval 4.05 to 5.99) than in patients without CHF. In conclusion, CHF occurs frequently in patients with NSTE ACS but is associated with less aggressive treatment and a higher risk of mortality. Further study is needed to determine the causes of these treatment differences and the optimal therapeutic approach for patients with NSTE ACS and concomitant CHF. (c) 2006 Elsevier Inc. All rights reserved.