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Researchers say efforts still fall short in improving heart failure outcomes.

ORLANDO, FLA—Heart failure causes about 300 000 deaths annually in the United States, yet progress in treating it remains frustratingly slow, according to researchersspeakingat thescientific sessions of the American College of Cardiology(ACC)meetingheldhereinMarch. Although patients admitted with acute heart failure syndromes appear to improve during hospitalization, they have high postdischarge mortality and readmission rates. This situation results, in part, because of underutilization of many effective therapies. About 20% of patients diagnosed as having heart failure die within a year. Among patients older than 65 years, it is the most common diagnosis at hospital discharge and the primarycauseof readmissionwithin60days of leaving the hospital (Shah SJ and Gheorghiade M. JAMA. 2008;300[4]: 431-433). The American Heart Association estimates the direct and indirect cost of heart failure for 2009 at more than $37 billion, with a significant portion reflecting rehospitalization. The federal government has stepped up its scrutiny of inappropriate rehospitalization from all causes and has launched a 14-site pilot program to test novel strategies to improve the delivery of care and reduce rehospitalization rates for the overall Medicare patient population. A recent study found that about 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days; that proportion rose to 34% within 90 days. Heart failure accounted for more of these rehospitalizations than any other single cause (Jencks SF et al. N Engl J Med. 2009;360[14]:1418-1428). Specialty societies also seek ways to lower rehospitalization rates for patients with heart failure. At the ACC meeting, the college announced its program to reduce heart failure rehospitalization rates by 20% by the end of 2012. The ACC’s plan, Hospital-to-Home, or H2H, will focus on improving the “handoff” for patients with heart failure when they are discharged from the hospital and resume care in the community setting. But Mihai Gheorghiade, MD, of Northwestern University’s Feinberg School of Medicine in Chicago, said that further research is needed. “In order to achieve this goal, it is essential to understand the causes of rehospitalization,” said Gheorghiade in an interview. Gheorghiade said he believed rehospitalization rates would decrease if patients received optimal care while hospitalized. He noted that while in the hospital, a patient with heart failure will typically be treated for signs and symptoms, but concomitant cardiac or noncardiac conditions, such as coronary arterydisease,leftventriculardyssynchrony, and impaired renal function, are not aggressively pursued. “Although some of thecomorbiditiesarenotbeingaddressed and evidence-based therapy is not optimized, the patient is sent home because the patient feels much better and the health care team is happy and feels that the mission is accomplished,” he said. GreggC.Fonarow,MD,of theUniversityofCalifornia,LosAngelesDavidGeffen School of Medicine, agreed that physicians treatinghospitalizedheart failure patients must do better. A 2005 study found that while 86% of patients admitted for heart failure received assessment of leftventricular function,only43%had smokingcessationcounselingand fewer than1in4receiveddischargeinstructions (FonarowGCetal.ArchInternMed.2005; 165[13]:1469-1477). Fonarowsaidtreatments that improve heart failure outcomes are available but underused. “We have therapies that are remarkably beneficial for patients with heart failureandreduced left ventricular function, but when you look at the core medicationsavailable,sometimes5ofthe 6 therapies are omitted,” he said. Gheorghiade said that subsets of patientswithacuteheart failuresyndromes have the opportunity to do better with optimal treatment. He adds, however, that there is little researchdefining these categories. “When you admit patients with heart failure, you can divide them into2groups: thosewithadvancedheart failure—and no matter what you do to them, they will do poorly—and the rest who have cardiac reserve, and you can significantly improve their cardiac function,”hesaid. “Let’s identify thepatients who will respond to therapy.”