Impact of Time of Hospital Presentation in Acute HF

Study Questions:

What is the relationship between time of hospital presentation, clinical profile, inpatient management, and outcomes among patients admitted for acute heart failure (AHF)?

Methods:

The study investigators conducted a post hoc analysis of the ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial that enrolled 7,141 patients hospitalized for AHF. They defined patients based on when they presented to the hospital; regular hours were defined as 9 AM to 5 PM, Monday through Friday, and off hours were defined as 5 PM to 9 AM, Monday through Friday and weekends. Clinical characteristics and outcomes were compared by time of presentation. Logistic regression models were used to assess the association among time of presentation and 30-day mortality and re-hospitalization, 30-day mortality, and 30-day re-hospitalization. Cox regression models were used to assess the association between time of presentation and 180-day mortality. Unadjusted analyses for 30-day and 180-day outcomes controlled for geographic region.

Results:

Overall, 46% of the patients (n = 3,298) presented during off hours. Off-hour patients were more likely to have orthopnea (80% vs. 74%, respectively) and rales (56% vs. 49%, respectively) than regular-hour patients. Off-hour patients were more likely to receive intravenous (IV) nitroglycerin (18% vs. 11%, respectively) and IV loop diuretics (92% vs. 86%, respectively) as initial therapy and reported greater relief from dyspnea at 24 hours (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.04-1.24; p = 0.01) than regular-hour patients. Patients in the off-hour group had significantly shorter hospitalizations (mean: 7.18 days vs. 8.04 days, respectively) than those admitted during regular hours, even after adjustment for covariates (OR, 0.93; 95% CI, 0.89-0.95). A two-way interaction analysis demonstrated that the association between time of presentation and length of hospitalization was not modified by geographic region (p = 0.60 after adjustment). After adjustment, off-hour presentation was associated with significantly lower 30-day mortality (OR, 0.74; 95% CI, 0.57-0.96; p = 0.03) and 180-day mortality (hazard ratio [HR], 0.82; 95% CI, 0.72-0.94; p = 0.01), but similar 30-day rehospitalization rates (p = 0.40).

Conclusions:

The authors concluded that AHF patients admitted during off hours exhibited a distinct clinical profile, experienced greater relief of shortness of breath, and had lower post-discharge mortality than regular-hour patients.

Perspective:

This is an interesting study because it suggests that the risk profile of patients presenting during off-hours may be different from those presenting at regular hours. As the authors point out, these findings may impact the design of future clinical trials of AHF. On a separate note, the baseline renal function was remarkably ‘preserved’ in this cohort of AHF patients.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Dyspnea, Geriatrics, Heart Failure, Hospital Mortality, Inpatients, Natriuretic Peptide, Brain, Nitroglycerin, Patient Discharge, Respiratory Sounds, Treatment Outcome


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