Impact of Time of Hospital Presentation in Acute HF
What is the relationship between time of hospital presentation, clinical profile, inpatient management, and outcomes among patients admitted for acute heart failure (AHF)?
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.
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).
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.
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.
Keywords: Dyspnea, Geriatrics, Heart Failure, Hospital Mortality, Inpatients, Natriuretic Peptide, Brain, Nitroglycerin, Patient Discharge, Respiratory Sounds, Treatment Outcome
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