Acute decompensated heart failure is routinely treated as a cardiopulmonary syndrome

Abstract

Background: Heart failure as recognized and treated in typical practice may represent a complex condition that defies discrete categorizations. To illuminate this complexity, we examined treatment strategies for patients hospitalized and treated for decompensated heart failure. We focused on the receipt of medications appropriate for other acute conditions associated with shortness of breath including acute asthma, pneumonia, and exacerbated chronic obstructive pulmonary disease.

Methods and results: Using Premier Perspective(®), we studied adults hospitalized with a principal discharge diagnosis of heart failure and evidence of acute heart failure treatment from 2009-2010 at 370 US hospitals. We determined treatment with acute respiratory therapies during the initial 2 days of hospitalization and daily during hospital days 3-5. We also calculated adjusted odds of in-hospital death, admission to the intensive care unit, and late intubation (intubation after hospital day 2). Among 164,494 heart failure hospitalizations, 53% received acute respiratory therapies during the first 2 hospital days: 37% received short-acting inhaled bronchodilators, 33% received antibiotics, and 10% received high-dose corticosteroids. Of these 87,319 hospitalizations, over 60% continued receiving respiratory therapies after hospital day 2. Respiratory treatment was more frequent among the 60,690 hospitalizations with chronic lung disease. Treatment with acute respiratory therapy during the first 2 hospital days was associated with higher adjusted odds of all adverse outcomes.

Conclusions: Acute respiratory therapy is administered to more than half of patients hospitalized with and treated for decompensated heart failure. Heart failure is therefore regularly treated as a broader cardiopulmonary syndrome rather than as a singular cardiac condition.

Figure 1. Longitudinal treatment pathways.

A sample pathway is shown for a patient who receives treatment for heart failure and bronchodilators during the first 2 hospital days and acute respiratory treatment only during hospital days 3 through 5. Acute respiratory treatment includes treatment with short-acting inhaled bronchodilators, antibiotics, or corticosteroids. Within each time period, treatment groups are mutually exclusive and inclusive of all patients. HF, heart failure.

Figure 2. Proportion of hospitalizations receiving short-acting inhaled bronchodilators, antibiotics, and high-dose corticosteroids during the first 2 hospital days and hospital days 3 through 5.

Figure A shows results for all heart failure hospitalizations (n=164,494). Figure B shows results for heart failure hospitalizations with chronic lung disease (n=60,690). HF, heart failure.

Figure 3. Daily treatment during hospital days 3 through 5 for patients in each initial treatment group.

Percentages reflect the division of patients within each of the 5 initial treatment groups into 1 of 5 continuing treatment pathways. Pathways are mutually exclusive and exhaustive of all patients within the study sample. Non-labeled categories have percentages less than 5%. The 5 initial treatment groups were defined by the receipt during the first 2 hospital days of (1) heart failure treatment only (HF only); (2) heart failure treatment plus inhaled bronchodilators only (HF + Bronchodilators); (3) heart failure treatment plus antibiotics with or without inhaled bronchodilators (HF + Antibiotics (± Bronchodilators)); (4) heart failure treatment plus corticosteroids with or without inhaled bronchodilators (HF + Corticosteroids (± Bronchodilators)); or (5) heart failure treatment plus antibiotics and corticosteroids with or without inhaled bronchodilators (HF + Antibiotics + Corticosteroids (± Bronchodilators)). Treatment during hospital days 3 through 5 could fall into 1 of the 5 following categories: (1) discharge after hospital day 2 so ineligible for continuing therapy; (2) no daily heart failure or respiratory treatments during days 3 through 5; (3) daily heart failure treatment only (HF only); (4) daily acute respiratory treatment only (RT only); and (5) daily heart failure treatment plus daily acute respiratory treatment (HF + RT). HF, heart failure; RT, respiratory therapy.