BACKGROUND:The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population. METHODS AND RESULTS:INTERMACS 1 LVAD recipients from five U.S. centers were included. In-hospital and one-year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non-ECMO patients by propensity-weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one-year outcomes. One hundred and twenty-seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06-9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non-ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non-ECMO: 4.9%, p = 0.006). Among the study cohort, one-year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients. CONCLUSIONS:Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one-year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices.

Background The Impella (ABIOMED, Danvers, MA) is a temporary left ventricular support device, intended for short-term cardiac support for percutaneous procedures and cardiac shock. The Impella device is available in several sizes capable of producing different flows. It is FDA approved for up to 6 days of support. The device can provide significantly higher blood flow than an intra-aortic balloon pump and can be implanted percutaneously. We sought to describe potential complications and outcomes associated with extended Impella use for cardiogenic shock. Methods We retrospectively evaluated patients who underwent implantation of either the Impella CP (Impella 3.5) or Impella 5.0 from September 1, 2017 to September 1, 2019 at our institution. Hemolysis was defined as plasma free hemoglobin level > 50 mg/dL, a lactate dehydrogenase (LDH) level > 500 units/L, and bilirubin increase > 1 mg/dL. Results 58 patients underwent percutaneous insertion of an Impella device, with the indication of cardiogenic shock in 32 patients (55%). In these 32 patients, only one had an Impella 2.5 device, 21 had an Impella CP (66%), and 10 (31%) had an Impella 5.0. The average age at time of implantation was 55 ± 17 years, and 25 patients were male (78%). Ejection fraction was 17 ± 11.7%. The average duration of Impella support was 5.5 days (1, 16 days). Complications included hematoma at the time of insertion (3 patients), leg ischemia (2 patients), improper positioning (7 patients), acute renal failure (28 patients), and hemolysis (20 patients). Hemolysis developed in 12 patients (57%) with the Impella CP and in 8 patients (80%) with the Impella 5.0, with an average LDH of 1452 units/L. 8 patients were transitioned to veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), with the Impella utilized for left ventricular venting. 9 patients (28%) eventually underwent durable left ventricular assist device (LVAD) implantation on average 7 ± 6.1 days after Impella, and two patients underwent heart transplantation, both 9 days following Impella insertion. 23 patients (72%) did not survive past the initial hospitalization. Conclusion The Impella is a percutaneous temporary left ventricular support device used to provide additional cardiac output in patients with cardiogenic shock. Serious complications can occur with extended support, including hemolysis, acute renal failure, and high mortality. Of our 28 patients who received an Impella, 11 were able to be successfully bridged to either LVAD or heart transplantation with the Impella.

Objectives We investigated sex-based differences in eligibility for and outcomes after receipt of advanced heart failure (HF) therapies. Background Although women are more likely to die from HF than men, registry data suggest that women are less likely to receive heart transplant (HT) or left ventricular assist device (LVAD) for largely unknown reasons. Methods We performed a single-center retrospective cohort study of patients evaluated for advanced HF therapies from 2012 to 2016. Logistic regression was used to determine the association of sex with eligibility for HT/LVAD. Competing risks and Kaplan-Meier analysis were used to examine survival. Results Of 569 patients (31% women) evaluated, 223 (39.2%) were listed for HT and 81 (14.2%) received destination (DT) LVAD. Women were less likely to be listed for HT (adjusted odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61; P < .0001), based on allosensitization (P < .0001) and obesity (P = .02). Women were more likely to receive DT LVAD (adjusted OR 2.29, 95% CI 1.23-4.29; P = .01). Survival was similar between men and women regardless of whether they received HT and DT LVAD or were ineligible for therapy. Conclusion Women are less likely to be HT candidates, but more likely to receive DT LVAD.

Introduction The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) score assesses psychosocial and behavioral risk in patients who are undergoing evaluation for heart transplant. The SIPAT score is associated with adverse outcomes including increased rates of rejection, admissions and infections post-transplant. Many Stage D heart failure patients will undergo SIPAT testing, with some receiving an LVAD as bridge to transplant (BTT) and other as destination therapy (DT). However, the role of SIPAT scores in left ventricular assist devices (LVAD) patients remains unclear based on a limited number of studies. The objective of this study assesses whether SIPAT scores were associated with increased mortality. Methods SIPAT scores were documented by a Licensed Master Social Worker for 137 LVAD patients (mean age: 50.0±13 years 35.8% female, 59.8% black)including BTT and DT (57.7%) implanted at Emory University Hospital from 2010 to 2018. The total SIPAT score is comprised of 4 subscales that represent different psychosocial domains: A - patient readiness and illness management, B - social support system, C - psychological stability and psychopathology, and D—lifestyle and substance abuse. Multivariable Cox regression models were used to examine the association of SIPAT scores with mortality. Results During a follow-up period of 1.58 years [IQR 0.8-2.87], 53 patients (38.7%) died. The mean total SIPAT score was 7.45 ±8.06, and 92.0% of patients classified as excellent-good candidates (total SIPAT score ≤20). There was no association between total SIPAT scores and mortality in the total cohort. However, the SIPAT B subscale was associated with mortality in men after adjusting for age, race, albumin, and renal function (SIPAT B *sex interaction P=0.009). Men who died had a higher mean score on the SIPAT B subscale than those who did not (2.00 ± 3.65 vs. 0.63 ± 1.63, p=0.05). Sex-stratified Cox models demonstrated that the SIPAT B subscale was associated with mortality in men (adjusted HR: 1.39, 95% CI 1.11-1.75, p=0.004); but not in women (p=0.4). Conclusions In patients with LVAD, the SIPAT B subscale was associated with an increased risk of mortality in men. These findings suggest that social support may play an even greater role for male patients with LVAD as compared to females. More research is needed to determine which factors clearly define the association between social support and mortality in the LVAD population.

Background: Medicaid insurance in Georgia provides limited reimbursement for heart transplant (HT) and left ventricular assist devices (LVAD). We examined whether insurance type affects eligibility for and survival after receipt of HT or LVAD. Methods and Results: We retrospectively identified patients evaluated for HT/LVAD from 2012 to 2016. We used multivariable logistic and Cox proportional hazards regression to examine the association of insurance type on treatment eligibility and 1year survival. Of 569 patients evaluated, 282 (49.6%) had private, 222 (39.0%) had Medicare, and 65 (11.4%) had Medicaid insurance. Patients with Medicaid were younger, more likely to be Black, with fewer medical comorbidities. In adjusted models, Medicare and Medicaid insurance predicted lower odds of eligibility for HT, but did not affect survival after HT. Among those ineligible for HT, Medicaid patients were less likely to receive destination therapy (DT) LVAD (adj OR 0.08, 95% CI 0.010.66; P = .02) and had increased risk of death (adj HR = 2.03, 95% CI 1.13-3.63; P = .01). Conclusions: Despite younger age and fewer comorbidities, patients with Medicaid insurance are less likely to receive DT LVAD and have an increased risk of death once deemed ineligible for HT. Medicaid patients in Georgia need improved access to DT LVAD.

Hemodynamically significant outflow graft stenosis is a rare but potentially life-threatening complication of continuous flow left ventricular assist device (CF-LVAD) therapy. Causes include outflow graft thrombosis, kinking, compression from fibrinous exudate buildup between the outflow graft and bend–relief and/or protective outer graft as well as anastomosis-site stenosis that ultimately lead to low flow alarms and symptoms consistent with heart failure. Surgical replacement is curative; however such procedures are technically challenging and carry substantial peri-operative risk. Minimally invasive percutaneous interventions are attractive alternatives but data supporting such an approach is extremely limited. Here we present a case-series of three outflow graft stenoses including HeartMate II and HeartWare devices. In all cases, patients presented with low flow alarms, reduced power and progressive fatigue with one individual developing acute pulmonary edema. Doppler echocardiography as well as dedicated contrast-enhanced cardiac CT revealed hemodynamically significant outflow graft stenosis. Up to four bare metal stents were placed under general anesthesia into the grafts reducing the gradient by 80–90%. Reported CF-LVAD flow and pump power increased significantly immediately post-procedure, permitting optimization of pump parameters. Symptoms resolved shortly after graft stenting. One patient underwent successful heart transplantation 13 months post procedure and we detected no recurrence of stenosis at an average of 5.5 months. There were no procedural complications confirming that percutaneous therapy is a safe and highly effective intervention for CF-LVAD outflow graft kinking/stenosis when performed in a high-volume center by an experienced heart team.

Background: Psychosocial predictors of LVAD outcomes have not been standardized. There is limited data on objective psychosocial predictors of LVAD outcomes. The SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) scale has been validated in organ transplant evaluation and patient selection. A SIPAT score of less than 20 suggests an acceptable candidate, a SIPAT score of between 20–40 suggests a minimally acceptable candidate, and a SIPAT score of greater than 40 suggests a poor candidate. We hypothesized that SIPAT scale can be used in psychosocial risk assessment of VAD candidates. Methods: We retrospectively reviewed and identified patients evaluated for LVAD since January 2014 and subsequently deemed to be poor candidates for LVAD therapy. Retrospective SIPAT scores were performed on these patients. We divided patients turned down for LVAD based on medical risk factors and social risk factors. Scoring was based on evaluations by licensed clinical and medical social workers. Results: Among all patients who did not receive a VAD (n = 54), 31 had a complete LVAD evaluation. Of these, 13 were deemed to be at high psychosocial risk and were declined specifically for psychosocial reasons. These patients had mean SIPAT 31. Subscore A (measure of insight, motivation, compliance) was the greatest contributor to the total score. By comparison with other non-candidates, patients turned down for LVAD for psychosocial concerns tended to be non-white (71% vs 41%), not married (65% vs 24%), younger, were less likely to have pursued post-secondary education (24% vs 57%), and were predominantly considered for DT VAD (82% vs 54%). Conclusions: Psychosocial risk factors for LVAD therapy have not been standardized and may differ from heart transplant risk factors. We found a high percentage of patients who were turned down for LVAD were declined explicitly for psychosocial risk factors. The average SIPAT score in these patients was 31, in the minimally acceptable range. The SIPAT score may not be sensitive enough for psychosocial risk assessment of VAD candidates.

Background: Medicaid patients with advanced heart failure (HF) rarely receive left ventricular assist devices (LVAD) at our center due to significant reimbursement constraints from the Georgia Depa...

International mechanical circulatory support guidelines recommend pre-operative screening for intracardiac thrombus prior to placement of a left ventricular assist device (LVAD). No data exists on the prevalence of left ventricular (LV) thrombus in advanced heart failure patients referred for LVAD evaluation.

Race/ethnic disparities in survival after heart transplantation (HT) have been well described, with Blacks having a higher incidence of graft failure (GF) after HT. However, the race-specific differences in the epidemiology of GF remain poorly understood. We studied 15,255 patients (mean age 52±12 years; 76% men) who underwent primary HT from 2000 to 2012. We assessed the likelihood of GF, and population-attributable risk (PAR) of independent risk factors for GF. Over a median follow-up of 4.7 years, 2926 (19.2%) patients developed GF. Blacks were more likely to develop GF than Hispanics or Whites (23.6% vs. 19.2% vs. 18.2%, p<0.001). Blacks were more likely to have risk factors for GF, including rejection requiring hospitalization, nonadherence, human leukocyte antigen (HLA) mismatch at ≥5 loci, and panel reactive antibody (PRA) ≥10% (Table 1, all p<0.001). After adjustment for all risk factors in Table 1, Black race was associated with a higher risk of GF (hazard ratio [HR] 1.4; 95% confidence interval [CI] 1.2-1.6, p<0.001). Rejection requiring hospitalization carried the highest PAR in all groups. Younger age at transplant and PRA ≥10% carried a high PAR in Blacks, while donor age carried a high PAR in Whites and Hispanics. Immunologic factors accounted for the highest overall proportion of GF in all groups, while sociodemographic and donor factors accounted for relatively less. GF is common after HT, however only a small proportion of GF risk can be attributed to modifiable risk factors. Racial differences in risk factors for GF after HT need to be considered in prevention and treatment efforts.Table 1Race-stratified adjusted HR and PAR of risk factors for graft failureRisk FactorWhites (N=11,465)Blacks (N=2653)Hispanics (N=1137)N (%)HR (95% CI); PAR %N (%)HR (95% CI); PAR %N (%)HR (95% CI); PAR %Age, yrs•40-59•18-39•60+6090 (53)1549 (14)3826 (33)Reference1.1 (0.9-1.3); ---1.2 (1.1-1.4); 6.91524 (57)682 (26)447 (17)Reference1.5 (1.2-1.9); 11.61.1 (0.8-1.5); ---646 (57)251 (22)240 (21)Reference1.4 (0.9-2.1); ---1.2 (0.8-2.0); ---Creatinine ≥2 mg/dL759 (7)1.2 (0.9-1.4); ---234 (9)1.1 (0.8-1.5); ---58 (5)0.7 (0.3-1.8); ---Less than College Education4208 (45)1.2 (1.1-1.3); 7.71230 (56)1.1 (0.9-1.3); ---597 (67)0.9 (0.6-1.4); ---Public Insurance4247 (37)1.1 (1.0-1.3); 5.01407 (53)0.9 (0.8-1.2); ---678 (60)0.9 (0.6-1.3); ---PRA ≥10%1998 (19)1.2 (1.0-1.4); 3.8645 (26)1.3 (1.0-1.6); 6.6190 (18)1.4 (0.8-2.2); ---HLA mismatch ≥5 loci5500 (57)1.2 (1.1-1.3); 10.01542 (68)0.9 (0.7-1.1); ---610 (61)1.0 (0.7-1.5); ---Medication nonadherence330 (3)1.8 (1.5-2.3); 2.4163 (6)1.7 (1.3-2.3); 4.344 (4)2.1 (1.2-3.7); 4.1Rejection requiring hospitalization1643 (14)2.5 (2.2-2.8); 17.4644 (24)2.3 (1.8-2.8); 23.3217 (19)1.8 (1.2-2.7); 13.1Cardiac allograft vasculopathy3169 (28)0.8 (0.7-0.9); ---678 (26)0.7 (0.6-0.9); ---283 (25)0.8 (0.5-1.2); ---Ischemic Time ≥4 hrs2280 (21)1.0 (0.9-1.1); ---459 (18)1.2 (0.9-1.5); ---247 (22)1.1 (0.7-1.7); ---Donor age ≥29 yrs5852 (51)1.3 (1.1-1.4); 11.51339 (51)1.2 (0.9-1.5); ---516 (45)1.4 (1.0-2.1); 16.9 Open table in a new tab

Background: Handgrip strength test quantifies the amount of static force that the hand can squeeze around a dynamometer and is associated with increased mortality in middle-aged and older adults, and in patients with chronic diseases. The prognostic role of handgrip strength in heart failure (HF) has not been fully investigated. Methods: A hydraulic hand dynamometer was used to measure handgrip strength in 317 outpatients with HF enrolled in The Atlanta Cardiomyopathy Consortium (TACC) cohort study. Patients repeated the test 3 times in each hand and the average from both hands was used. We defined poor handgrip strength based on age- and gender-specific normative data. We evaluated the association between poor handgrip strength and major clinical event (death, heart transplant, left ventricular assist device) and healthcare resource utilization. Results: Baseline patient characteristics are presented in Table 1; 228 patients (71.9%) had poor handgrip strength. Total follow-up was 911 patient-years; 55 patients (17.4%) experienced a major clinical event. There was a total of 836 all-cause hospitalizations with an average length of stay of 4.7 days. Poor handgrip strength was not significantly associated with major clinical events (hazard ratio (HR) 1,19; 95% CI: 0.64 to 2,21; P=0.59). However, patients with poor strength had 42% higher hospitalization rate (95% CI: 1.3% to 98%; P=0.042) and spent 85% (95% CI: 10% to 210%; P=0.020) more days in the hospital. Average length of stay among patients with poor handgrip strength was 4.9 days vs. 4.2 days in those with preserved strength. Conclusion: Poor handgrip strength is highly prevalent among HF patients and is associated with higher healthcare resource utilization and length of stay.

Heart failure (HF) prevalence continues to increase and is associated with a high mortality, morbidity, and cost burden for the society [ 1 Hunt S.A. Abraham W.T. Chin M.H. Feldman A.M. Francis G.S. Ganiats T.G. et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005; 112: e154-e235 Crossref PubMed Google Scholar , 2 Lloyd-Jones D. Adams R.J. Brown T.M. Carnethon M. Dai S. De Simone G. et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010; 121: e46-e215 Crossref PubMed Scopus (1380) Google Scholar ]. The most common cause of HF in the United States is coronary artery disease [ [3] He J. Ogden L.G. Bazzano L.A. Vupputuri S. Loria C. Whelton P.K. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med. 2001; 161: 996-1002 Crossref PubMed Scopus (904) Google Scholar ]. Left ventricular (LV) dysfunction, irrespective of the cause of heart failure (HF), leads to perturbed wall stress resulting in remodeling and HF progression. Matrix metalloproteinases (MMP) are a family of proteolytic enzymes that are involved in the protein degradation in the extracellular matrix and play an important role in remodeling [ 4 Spinale F.G. Myocardial matrix remodeling and the matrix metalloproteinases: influence on cardiac form and function. Physiol Rev. 2007; 87: 1285-1342 Crossref PubMed Scopus (883) Google Scholar , 5 Visse R. Nagase H. Matrix metalloproteinases and tissue inhibitors of metalloproteinases: structure, function, and biochemistry. Circ Res. 2003; 92: 827-839 Crossref PubMed Scopus (3572) Google Scholar ]. Multiple classes of MMPs have been identified in human myocardium [ 5 Visse R. Nagase H. Matrix metalloproteinases and tissue inhibitors of metalloproteinases: structure, function, and biochemistry. Circ Res. 2003; 92: 827-839 Crossref PubMed Scopus (3572) Google Scholar , 6 Spinale F.G. Matrix metalloproteinases: regulation and dysregulation in the failing heart. Circ Res. 2002; 90: 520-530 Crossref PubMed Scopus (628) Google Scholar ]. Certain MMPs, specifically MMP-2, MMP-3, and MMP-9 have been shown to have high expression in the left ventricle [ 7 Thomas C.V. Coker M.L. Zellner J.L. Handy J.R. Crumbley III, A.J. Spinale F.G. Increased matrix metalloproteinase activity and selective upregulation in LV myocardium from patients with end-stage dilated cardiomyopathy. Circulation. 1998; 97: 1708-1715 Crossref PubMed Scopus (415) Google Scholar , 8 Coker M.L. Thomas C.V. Clair M.J. Hendrick J.W. Krombach R.S. Galis Z.S. et al. Myocardial matrix metalloproteinase activity and abundance with congestive heart failure. Am J Physiol. 1998; 274: H1516-H1523 PubMed Google Scholar ]. Tissue inhibitors of metalloproteinases (TIMPS) are low-molecular-weight molecules that bind to MMPs forming MMP–TIMP complexes that exhibit an inhibitory control on MMPs. Several studies have delineated the relationship between MMPs and TIMPs, and that the changes in the MMP/TIMP ratio correlate with left ventricular hypertrophy and dilation [ 9 Li Y.Y. Feldman A.M. Sun Y. McTiernan C.F. Differential expression of tissue inhibitors of metalloproteinases in the failing human heart. Circulation. 1998; 98: 1728-1734 Crossref PubMed Scopus (328) Google Scholar , 10 Lopez B. Gonzalez A. Querejeta R. Larman M. Diez J. Alterations in the pattern of collagen deposition may contribute to the deterioration of systolic function in hypertensive patients with heart failure. J Am Coll Cardiol. 2006; 48: 89-96 Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar ]. Loss of inhibitory control of TIMP on MMP correlates with progression of left ventricular remodeling via increased MMP activity, extracellular matrix proteolysis, and myocardial remodeling changes [ [11] Rouet-Benzineb P. Buhler J.M. Dreyfus P. Delcourt A. Dorent R. Perennec J. et al. Altered balance between matrix gelatinases (MMP-2 and MMP-9) and their tissue inhibitors in human dilated cardiomyopathy: potential role of MMP-9 in myosin-heavy chain degradation. Eur J Heart Fail. 1999; 1: 337-352 Crossref PubMed Scopus (107) Google Scholar ]. There have been conflicting reports on MMPs and TIMPs levels association with HF outcomes [ 12 Jordan A. Roldan V. Garcia M. Monmeneu J. de Burgos F.G. Lip G.Y. et al. Matrix metalloproteinase-1 and its inhibitor, TIMP-1, in systolic heart failure: relation to functional data and prognosis. J Intern Med. 2007; 262: 385-392 Crossref PubMed Scopus (35) Google Scholar , 13 George J. Patal S. Wexler D. Roth A. Sheps D. Keren G. Circulating matrix metalloproteinase-2 but not matrix metalloproteinase-3, matrix metalloproteinase-9, or tissue inhibitor of metalloproteinase-1 predicts outcome in patients with congestive heart failure. Am Heart J. 2005; 150: 484-487 Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar , 14 Frantz S. Stork S. Michels K. Eigenthaler M. Ertl G. Bauersachs J. et al. Tissue inhibitor of metalloproteinases levels in patients with chronic heart failure: an independent predictor of mortality. Eur J Heart Fail. 2008; 10: 388-395 Crossref PubMed Scopus (59) Google Scholar , 15 Radauceanu A. Ducki C. Virion J.M. Rossignol P. Mallat Z. McMurray J. et al. Extracellular matrix turnover and inflammatory markers independently predict functional status and outcome in chronic heart failure. J Card Fail. 2008; 14: 467-474 Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar , 16 Banfi C. Cavalca V. Veglia F. Brioschi M. Barcella S. Mussoni L. et al. Neurohormonal activation is associated with increased levels of plasma matrix metalloproteinase-2 in human heart failure. Eur Heart J. 2005; 26: 481-488 Crossref PubMed Scopus (54) Google Scholar , 17 Yamazaki T. Lee J.D. Shimizu H. Uzui H. Ueda T. Circulating matrix metalloproteinase-2 is elevated in patients with congestive heart failure. Eur J Heart Fail. 2004; 6: 41-45 Crossref PubMed Scopus (74) Google Scholar ]. These studies have generally not assessed the multiple members of the MMP and TIMP family simultaneously and have assessed varying HF outcomes. In this study, we sought to assess the association between multiple MMPs and TIMPs with clinical outcomes, health status, and exercise capacity among HF patients.

Category: 24. Myocardial Function/Heart Failure—Clinical Nonpharmacological TreatmentSession-Poster Board Number: 1160-25Authors: Catherine Norton, Vasiliki Georgiopoulou, Andreas Kalogeropoulos, Lucy Fike, Grigorios Giamouzis, Sonjoy Laskar, Robert Cole, Andrew Smith, Wilson W.H. Tang, Sandra Dunbar, Javed Butler, Emory University School of Medicine, Atlanta, GA, Cleveland Clinic Foundation, Cleveland, OH Background: Cumulative adherence with self-care recommendations and association with outcomes is not well described in heart failure (HF) patients.Methods: We used self-report to evaluate adherence to eight HF self-care recommendations (exercise, medications, alcohol and smoking habits, diet, weight and symptom monitoring) among 286 patients with HF (age, 56±11.6 years; 34.3% female; 46.2% black). Adherence was defined as optimal (overall ≥80%) or ideal (≥80% adherence to each recommendation). Outcomes included death or transplant or ventricular assist device placement; rates of emergency department visits, hospitalizations, and length of stay; health status using the Kansas City Cardiomyopathy Questionnaire.Results: Mean follow-up was 525±295 days. Adherence to individual recommendations ranged from 89% for medication to 26% for exercise. Optimal adherence was reported by 34% of patients whereas only 11% indicated ideal adherence. Education was the only sociodemographic variable associated with adherence (odds ratio [OR] 1.15; 95% confidence interval [CI] 1.05-1.25 for optimal; and OR 1.15; 95% CI 1.02-1.30 for ideal adherence per year of education). Patients with optimal or ideal adherence had better clinical outcomes (Table); however, only ideal adherence was associated with better quality of life.Conclusions: In this HF cohort, better adherence with self-care recommendations was associated with improved clinical outcomes. However, adherence was suboptimal for most patients. Optimal AdherenceDeath/Left Ventricular Assist Device/Transplant, % 8.0 9.2 0.73All cause hospitalizations, per 1000 patient-days 2.8 2.0 0.07HF hospitalizations, per 1000 patient-days 1.2 0.9 0.12Emergency department visits, per 1000 patient-days 1.3 0.8 0.02Hospital length of stay, per 1000 patient-days 13.8 8.8 0.06Hospital length of stay - HF only, per 1000 patient-days 8.5 5.5 0.13Kansas City Cardiomyopathy Questionnaire Overall Summary Score 65.2±23.2 67.9±24.3 0.37Ideal AdherenceDeath/Left Ventricular Assist Device/Transplant, % 8.3 9.4 0.83All cause hospitalizations, per 1000 patient-days 2.7 1.5 0.09HF hospitalizations, per 1000 patient-days 1.2 0.4 0.08Emergency department visits, per 1000 patient-days 1.2 0.8 0.33Hospital length of stay, per 1000 patient-days 13.6 3.0 0.02Hospital length of stay - HF only, per 1000 patient-days 8.3 0.8 0.04Kansas City Cardiomyopathy Questionnaire Overall Summary Score 65.1±23.5 74.3±23.5 0.04

Patients with heart failure (HF) are hospitalized over a million times annually in the United States. Hospitalization marks a fundamental change in the natural history of HF, leading to frequent subsequent rehospitalizations and a significantly higher mortality compared with nonhospitalized patients. Three-fourths of all HF hospitalizations are due to exacerbation of symptoms in patients with known HF. One-half of hospitalized HF patients experience readmission within 6 months. Preventing HF hospitalization and rehospitalization is important to improve patient outcomes and curb health care costs. To implement cost-effective strategies to contain the HF hospitalization epidemic, optimal schemes to identify high-risk individuals are needed. In this review, we describe the risk factors that have been associated with hospitalization risk in HF and the various multimarker risk prediction schemes developed to predict HF rehospitalization. We comment on areas that represent gaps in our knowledge or difficulties in interpretation of the current literature, representing opportunities for future research. We also discuss issues with using HF readmission rate as a quality indicator.