ABSTRACT
Introduction: Select centers have published local experiences with outpatient (OP) intravenous (IV) diuretic clinics to treat worsening heart failure (HF) and prevent hospitalization. Little is known regarding widespread use of this care strategy in contemporary US practice, including the potential impact of the COVID-19 pandemic. Method(s): Inpatient (IP) and OP claims from Optum (April 2018-March 2021) were utilized to identify instances where patients with HF with reduced ejection fraction (HFrEF) received >=1 administration of IV diuretic. Episodes of care were categorized into hierarchical mutually exclusive groups defined by intensity of care setting, including IP hospitalization, critical care (without IP hospitalization), emergency department (without IP hospitalization), observation unit, nursing facility, and outpatient clinic. Analyses were stratified across pre-pandemic (4/2018-3/2019, 4/2019-3/2020) and COVID-19 pandemic periods (4/2020-3/2021). Result(s): Among 302,397 patients with HFrEF, 56,213 (19%) patients received IV diuretic therapy during the study period, accounting for 94,865 total IV diuretic episodes. Of patients receiving IV diuretics, 44% were female and 20% were Black. Among 85,827 (90%) IV diuretic episodes with available data on location of care, 14% were outpatient clinic visits, 60% were IP hospitalizations, and 21% were ED visits. Critical care, observation unit, and nursing facility locations each constituted ~1-2% of IV diuretic episodes. The proportion of outpatient IV diuretic visits and the overall distribution of IV diuretic episodes was similar over time, spanning the pre-pandemic and COVID-19 pandemic periods (Figure). Conclusion(s): In this cohort of US patients with HFrEF, approximately 1 in 7 care episodes involving IV diuretic therapy occurred in outpatient clinic. The relative proportion of outpatient IV diuretic visits did not meaningfully change during the first year of the COVID-19 pandemic. (Figure Presented).
ABSTRACT
Introduction: COVID-19's impact on in-hospital care quality and outcomes of patients hospitalized with acute heart failure (HF) has not been systematically evaluated nationally. Methods: Patients hospitalized with HF with ejection fraction (EF) <40% in the AHA GWTG-HF registry during the pandemic (3/1/2020 - 4/1/ 2021) and pre-pandemic (2/1/2019 - 2/29/2020) periods were included. Adherence to HF process of care measures, in-hospital mortality, and length of stay (LOS) were compared in the pre-pandemic vs pandemic period and among hospitalized HF patients with vs without COVID-19 across both periods. Results: 40,005 pre-pandemic and 35,561 pandemic period patients admitted across 346 centers (median age 68, 33% women, 58% White) were included. There were no differences in clinical characteristics, comorbidities, presentation vital signs, or EF during the pandemic vs pre-pandemic periods. Among process of care measures, utilization of guideline-directed medical therapy at discharge was comparable across both periods. In contrast, rates of ICD placement or prescription and blood pressure control at discharge were lower during the pandemic (vs pre-pandemic period) (Table). In-hospital death (2.5% vs. 3.0%, p<0.001) and LOS (mean 5.4 vs. 5.7 days, p=0.008) were higher during the pandemic vs pre-pandemic. Substantial geographic variation was seen in the inhospital death rates during the pandemic, with highest rates among patients hospitalized in the Northeast region (3.36%). Among HF patients hospitalized during the pandemic with COVID-19 (N = 527 [1.5%]), adherence to ICD placement or prescription at discharge and prescription of aldosterone antagonist or ACE/ARB/ARNi were lower, and risk of in-hospital death and length of stay were significantly higher than those without COVID-19. Conclusion: In-hospital mortality and adherence to certain quality measures worsened during COVID-19 pandemic among patients admitted for acute decompensated HFrEF.
ABSTRACT
Introduction: COVID-19 may negatively impact prognosis for patients with chronic HFrEF, and vice versa. However, large-scale data characterizing the interplay of COVID-19 and HFrEF on clinical outcomes are scarce. Methods: We examined the TriNetX health database from January 2020-September 2020 to conduct 2 analyses. Analysis A excluded patients with HFpEF and included patients with a positive inpatient or outpatient test for COVID-19, with a 3-way comparison of patients 1) without prior HF, 2) HFrEF without recent worsening HF event (WHFE) (i.e., no HF hospitalization or outpatient IV diuretic within prior 1 year), and 3) worsening HFrEF (i.e., HF hospitalization or outpatient IV diuretic within prior 1 year). Outcomes included mortality at 30 days and composite all-cause mortality or hospitalization following COVID-19 test. Analysis B included patients with HFrEF who underwent PCR testing for COVID-19, and compared patients with a positive versus negative test. Outcomes were mortality at 30 days and worsening HF (i.e., HF hospitalization or outpatient IV diuretic use). Results: In analysis A, 98,014 (99%) patients had no prior HF, 524 (0.5%) had HFrEF without WHFE, and 514 (0.5%) had worsening HFrEF. After adjustment for confounders, compared with patients without HF, worsening HFrEF was independently associated with excess mortality (p<0.01), whereas HFrEF without WHFE was not statistically significant (p=0.06) (Table). In analysis B, 1,038 (7%) had a positive test for COVID-19 and 13,800 (93%) had only negative tests. After adjustment, testing positive for COVID-19 was independently associated with mortality and worsening HF (all p<0.01). Conclusions: In this US population of ambulatory and hospitalized patients, after accounting for confounders, worsening HFrEF was independently associated with excess mortality after COVID-19 infection. Among patients with HFrEF, COVID-19 infection was associated with higher risk of death and worsening HF events.