Abstract and Introduction
Abstract
Study Objective. To determine whether controlling systolic blood pressure (SBP), pulse pressure, and heart rate in the outpatient setting is associated with decreased hospital utilization in patients with heart failure and preserved ejection fraction (PEF).
Design. Retrospective medical record review.
Setting. University-affiliated medical center and outpatient clinics.
Patients. One hundred forty adults admitted between January 1, 2003, and October 31, 2005, for an exacerbation of heart failure with PEF and followed for 2 years after their index admission.
Measurements and Main Results. Outpatient SBP, pulse pressure, and heart rate, and the percentage of clinic visits for which patients had each vital sign at a certain level were used for correlations and comparisons. These vital signs and percentages of clinic visits were varied until maximum significant differences were observed in total hospital utilization for each parameter. These values were then analyzed for differences based on age, race-ethnicity, and sex. When comparing patients whose vital signs were in control for at least 80% of clinic visits versus those whose were in control for less than 80% of clinic visits, significantly lower hospital utilization was associated with clinic SBP less than 140 mm Hg (median hospital utilization 3 vs 5 visits, p=0.0252), pulse pressure less than 65 mm Hg (3 vs 5 visits, p=0.0113), and heart rate of 55–70 beats/minute (2 vs 4 visits, p=0.0311). Among the 140 patients, 78 (56%) were Caucasian, 48 (34%) were Hispanic, and 14 (10%) were African-American. The African-American patients were significantly younger (p=0.0218) and had significantly poorer SBP control (< 140 mm Hg for ≥ 80% of clinic visits: 14.3% vs 43.8%, p=0.0446) and higher hospital utilization (> 4 visits: 78.6% vs 43.8%, p=0.0218) than the Hispanic patients, despite similar percentages of missed clinic appointments (25% for each group).
Conclusion: Controlling SBP at less than 140 mm Hg, pulse pressure at less than 65 mm Hg, and heart rate at 55–70 beats/minute for at least 80% of clinic visits were factors associated with decreased hospital utilization. African-American patients with heart failure and PEF were younger, had more poorly controlled SBP, and had higher hospital utilization despite similar percentage of missed clinic visits as their Hispanic counterparts.
Introduction
Heart failure affects more than 5% of patients aged 65–75 years and 10–20% of patients older than 80 years. Heart failure is the leading cause of hospitalization in the United States and a leading cause of mortality. Hospitalizations for heart failure have tripled over the last 30 years. Roughly 50% of patients with heart failure have a preserved left ventricular ejection fraction (LVEF) of 45% or greater. The overall number of visits to the emergency department and hospital admissions, as well as costs, are similar between patients with heart failure and reduced ejection fraction (REF) and those with heart failure and preserved ejection fraction (PEF). In patients with heart failure who are aged 65 years or older, mortality is similar between those with PEF and those with REF; however, in patients younger than 65 years, mortality from heart failure with PEF is less than that from heart failure with REF. Heart failure is the most expensive Medicare diagnosis, and it was estimated that $37.2 billion was spent on heart failure in 2009. Because of the correlation with increasing age and increased incidence of heart failure with PEF, the prevalence of heart failure with PEF is expected to increase as the population ages.
Although extensive randomized controlled trials have been conducted in patients with heart failure with REF and heart failure as a whole, only a few randomized controlled trials have examined therapy related to outcomes in patients with heart failure and PEF. The American College of Cardiology–American Heart Association guidelines contain few specific recommendations for heart failure with PEF. These recommendations are as follows: control of systolic and diastolic hypertension in accordance with published guidelines (class I, level A); control of ventricular rate in patients with atrial fibrillation (class I, level C); control of pulmonary congestion and peripheral edema with diuretics (class I, level C); coronary revascularization in patients with coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to have an adverse effect on diastolic function (class IIa, level C); restoration of sinus rhythm in patients with atrial fibrillation (class IIb, level C); use of β-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or calcium channel antagonists in patients with controlled hypertension to minimize symptoms of heart failure (class IIb, level C); and use of digitalis to minimize symptoms of heart failure (class IIb, level C). The 2009 updated guidelines offer no additional recommendations for heart failure with PEF.
We found no studies that examined the effect of outpatient control of blood pressure or heart rate on outcomes specifically in patients with heart failure and PEF. One group of authors proposed that systolic blood pressure (SBP) be empirically maintained at less than 140 mm Hg because SBP is a direct measure of afterload. In addition, they proposed that heart rate should empirically be maintained at less than 80 beats/minute because chronically elevated ventricular rates reduce left ventricular filling times and may also contribute to tachycardia-related cardiomyopathy, thereby worsening heart failure with PEF. Overall, limited data and a lack of consensus exist to guide practitioners in the treatment of patients with heart failure and PEF. Thus, the purpose of our study was to determine whether controlling SBP, pulse pressure, and heart rate in the outpatient setting is associated with decreased hospital utilization in patients with heart failure and PEF.