Possible Warning Clinicians Can Miss Before a Heart Failure Admission

December 03, 2020

Some patients who end up in the hospital with a new diagnosis of heart failure (HF) may have unknowingly sent out early-warning signals of the looming acute event that went unrecognized by clinicians, a cohort study suggests.

The main finding, that such patients' contacts with healthcare providers rapidly multiplied throughout the preceding months, may point to "missed opportunities" for earlier HF diagnoses and initiation of therapies that might have prevented the hospitalizations, researchers say.

Their study compared three matched cohorts of more than 26,000 patients each who were hospitalized with either newly diagnosed HF or chronic obstructive pulmonary disease (COPD) or had stable HF.

The number of healthcare contacts — outpatient physician visits, hospitalizations for unrelated reasons, or emergency-department visits — in the three groups began to climb steadily during the preceding year, much more so for those ultimately diagnosed with HF or COPD. But the climb was earlier and steeper in patients who would be admitted with HF than in those with COPD, report Kim Anderson, MD, MSC, and colleagues in the December 1 issue of the Journal of the American College of Cardiology: Heart Failure.

Many patients with HF have their diagnosis made only when they are hospitalized, after they've seen multiple primary care and emergency physicians for essentially the same symptoms and apparently without suspicions of HF, Anderson, from Queen Elizabeth II Halifax Infirmary, Nova Scotia Health Authority, Canada, told theheart.org | Medscape Cardiology.

"No natriuretic peptide, no echocardiogram are requested. And often the patients will have gone through a course of multiple diagnoses, such as pneumonia or upper respiratory tract infection, and therefore receive inappropriate treatment," she observed. "Unfortunately, it's often after multiple interactions with their healthcare system that finally someone makes a diagnosis of heart failure."

The current analysis suggests that such cases aren't isolated, and that a jump in the frequency of contacts with clinicians, given a consistent symptom profile, might well be taken as a warning. "We think that at least one of the explanations for the increased healthcare contact before the hospitalization is a missed diagnosis of heart failure."

The study's main lesson, mostly for primary care and emergency physicians, "is that we must increase our suspicion of heart failure when we see patients with symptoms such as breathlessness, dyspnea, fatigue, or leg edema," Anderson said.

"Because providers may not recognize nonspecific symptoms such as dyspnea and fatigue as representing underlying HF, there may be opportunities to improve diagnostic accuracy and potentially avoid hospitalization," according to an editorial accompanying the analysis.

"The health system is well equipped to react to acute symptoms, but less well positioned to be proactive in identifying symptoms across time that may ultimately lead to a health event that requires hospitalization and may even be life-threatening," write Nihar R. Desai, MD, MPH, and Harlan M. Krumholz, MD, SM, both from Yale School of Medicine, New Haven, Connecticut.

But in a "digital data world" with HF monitoring systems, wearable monitors, and other such technology, "where clinical, patient-generated, and patient-reported data may flow into analytic engines," they continue, "there is the prospect of producing platforms that can dynamically assess risk and trigger interventions as necessary to mitigate the threat."

Also, they write, "we need to engage our colleagues in primary care, internal medicine, emergency medicine, and other disciplines that are likely to be among the first providers to evaluate a patient. Here, the development of clinical pathways or e-consults or other care models may help bring necessary clinical care to avoid HF hospitalization."

The study's three cohorts, comprising 26,463 patients each, were assembled from patients hospitalized with HF or COPD or who had stable HF among the adult population of Ontario, Canada, from 2006 through 2013. They were matched by age, sex, and local healthcare administrative region; mean age in each was 75 years, and 51% were women.

The cohorts were followed for number of healthcare contacts in the preceding year, broken down as thirteen 28-day periods before the incident hospitalization for HF or COPD or a corresponding time assigned to the patients with stable HF.

In multivariate analysis, the disparity between number of healthcare contacts for hospitalized HF vs COPD patients widened throughout most of the year preceding admission. The excess rate ratio for acute HF patients reached 13% in the third 28-day period before the acute event and 28% in the final 28 days (< .001 for both).

The hospitalized HF group started to overtake the stable HF cohort for number of such contacts starting at about the fourth most recent 28-day period preceding admission. The excess rate ratio for the acute HF group climbed sharply to 75% in the final 28 days (< .001).

A secondary multivariate analysis involved only patients hospitalized with HF and added members of the larger cohort who had not been part of the matching process. Any in long-term care facilities (who are typically sicker and have a different format of access to healthcare providers, the authors note) were excluded. This secondary cohort numbered 45,347.

Frequency of health-care contacts went up steadily across the year at each successive 28-day period before the HF hospitalization compared to the earliest 28-day period. The trend reached significance starting at the 11th such period prior to admission and grew exponentially for the rest of the year, exploding in the final month before the acute event.

Adjusted Rate Ratio (RR) for Combined Healthcare Contacts in Subsequent vs Earliest 28-day Periods Prior to HF Hospitalization
28-day Period Preceding HF Hospitalization Adjusted RR* (95% CI)
11th 1.01 (0.99–1.02)
9th 1.03 (1.01–1.04)
7th 1.06 (1.05–1.08)
5th 1.11 (1.09–1.13)
3rd 1.24 (1.23–1.26)
1st 1.94 (1.91–1.97)
*All RRs vs 13th (earliest) 28-day period preceding HF hospitalization P < .001, except for the 11th preadmission period as shown.

It's been demonstrated that natriuretic peptide point-of-care testing to aid diagnosis of HF can be "useful to decrease the number of repeated contacts for the same symptoms," Anderson said.

"We're very good now at doing a troponin to make sure we don't miss a myocardial infarction. We should be doing the same thing with heart failure." Natriuretic peptides, she said, are "the troponin of heart failure."

Anderson and her colleagues have no relevant disclosures. Desai reports working under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures used for public reporting and pay for performance program; and discloses receiving research grants from and consulting for Amgen, Astra Zeneca, Boehringer Ingelheim, Cytokinetics, Medicines Company, Relypsa, Novartis, and SCPharmaceuticals. Krumholz reports receiving contracts through Yale New Haven Hospital with the Centers for Medicare and Medicaid Services to support quality measurement programs and through Yale with UnitedHealth Group to engage in collaborative research; his other disclosures are in the report.

JACC Heart Fail. 2020;8:1024-1034. Full text, Editorial

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