Risk factors and clinical outcomes of functional decline during hospitalisation in very old patients with acute decompensated heart failure: an observational study

Hidenori Yaku; Takao Kato; Takeshi Morimoto; Yasutaka Inuzuka; Yodo Tamaki; Neiko Ozasa; Erika Yamamoto; Yusuke Yoshikawa; Takeshi Kitai; Masashi Kato; Tomoyuki Ikeda; Yutaka Furukawa; Yoshihisa Nakagawa; Yukihito Sato; Koichiro Kuwahara; Takeshi Kimura

doi:10.1136/bmjopen-2019-032674

February 1, 2020BMJ OpenOpen Access

Risk factors and clinical outcomes of functional decline during hospitalisation in very old patients with acute decompensated heart failure: an observational study

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Why the study?

The prevalence, risk factors, and relationship with postdischarge outcomes of in-hospital functional decline in very old patients hospitalised with acute decompensated heart failure were not well established.

Does functional decline during hospitalisation increase the risk of all-cause death or heart failure hospitalisation in very old patients with acute decompensated heart failure?

Key Points

To investigate the prevalence, risk factors, and postdischarge clinical outcomes associated with in-hospital functional decline in very old patients admitted for acute decompensated heart failure.
Multicenter trial evaluating consecutive patients admitted for acute decompensated heart failure across 19 hospitals in Japan between 1 October 2014 and 31 March 2016 (N=3555; median age 80 years; 44% women; trial registration NCT02334891, UMIN000015238).
Assessed functional decline during index hospitalization and tracked the 1-year composite primary outcome of all-cause death or heart failure rehospitalization using multivariable adjustment.
In-hospital functional decline occurred in 15% (528/3555) of patients, with key risk factors including age ≥80 years (OR 2.71; 95% CI 2.09 to 3.51), dementia (OR 2.26; 95% CI 1.74 to 2.95), elevated body temperature (OR 1.91; 95% CI 1.31 to 2.79), and renal dysfunction (OR 1.55; 95% CI 1.22 to 1.98).
The cumulative 1-year incidence of all-cause death or heart failure rehospitalization was 50% in the functional decline group versus 31% in the no functional decline group (log-rank p<0.001; adjusted HR 1.46; 95% CI 1.24 to 1.71; p<0.001).

Structured PICO

Does functional decline during hospitalisation increase the risk of all-cause death or heart failure hospitalisation in very old patients with acute decompensated heart failure?

P

Population

3,555 patients hospitalised for acute decompensated heart failure (ADHF), median age 80, 44% female, across 19 hospitals in Japan.

I

Intervention

Functional decline during index hospitalisation

C

Comparator

No functional decline during index hospitalisation

O

Outcome

Composite of all-cause death or heart failure (HF) hospitalisation after dischargecomposite

Functional decline during hospitalisation for acute decompensated heart failure is common in older patients and is independently associated with an increased risk of post-discharge mortality and heart failure readmission.

Implication

Functional decline during ADHF hospitalization was associated with worse postdischarge outcomes in very old patients; leaves open whether prevention alters prognosis.

Abstract

OBJECTIVE: To investigate the prevalence and risk factors of functional decline during hospitalisation and its relationship with postdischarge outcomes in very old patients with acute decompensated heart failure (ADHF) hospitalisation. DESIGN: Prospective cohort study between 1 October 2014 and 31 March 2016. SETTING: A physician-initiated, multicentre study of consecutive patients admitted for ADHF in 19 hospitals throughout Japan. PARTICIPANTS: Among 3555 patients hospitalised for ADHF (median age (IQR), 80 (71-86) years; 1572 (44%) women), functional decline during the index hospitalisation occurred in 528 patients (15%). PRIMARY AND SECONDARY OUTCOMES: The primary outcome measure was a composite of all-cause death or heart failure (HF) hospitalisation after discharge. The secondary outcome measures were all-cause death, HF hospitalisation, and a composite of all-cause death or all-cause hospitalisation. RESULTS: The independent risk factors for functional decline included age ≥80 years (OR 2.71; 95% CI 2.09 to 3.51), female (OR 1.32; 95% CI 1.05 to 1.67), prior stroke (OR 1.67; 95% CI 1.28 to 2.19), dementia (OR 2.26; 95% CI 1.74 to 2.95), ambulatory before admission (OR 1.74; 95% CI 1.29 to 2.35), elevated body temperature (OR 1.91; 95% CI 1.31 to 2.79), New York Heart Association class III or IV on admission (OR 1.54; 95% CI 1.07 to 2.22), decreased albumin levels (OR 1.76; 95% CI 1.32 to 2.34), hyponatraemia (OR 1.49; 95% CI 1.10 to 2.03) and renal dysfunction (OR 1.55; 95% CI 1.22 to 1.98), after multivariable adjustment. The cumulative 1-year incidence of the primary outcome in the functional decline group was significantly higher than that in the no functional decline group (50% vs 31%, log-rank p<0.001). After adjusting for baseline characteristics, the higher risk of the functional decline group relative to the no functional decline group remained significant (adjusted HR 1.46; 95% CI 1.24 to 1.71; p<0.001). CONCLUSIONS: Independent risk factors of functional decline in very old patients with ADHF were related to both frailty and severity of HF. Functional decline during ADHF hospitalisation was associated with unfavourable postdischarge outcomes. TRIAL REGISTRATION NUMBER: NCT02334891, UMIN000015238.