JACC: Heart Failure

Volume 6, Issue 4, April 2018 DOI: 10.1016/j.jchf.2018.01.018
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Is Time of the Essence? The Impact of Time of Hospital Presentation in Acute Heart Failure
Insights From ASCEND-HF Trial

Lukasz P. Cerbin, Andrew P. Ambrosy, Stephen J. Greene, Paul W. Armstrong, Javed Butler, Adrian Coles, Adam D. DeVore, Justin A. Ezekowitz, Adrian F. Hernandez, Marco Metra, Randall C. Starling, Wilson Tang, John R. Teerlink, Adriaan A. Voors, Angie Wu, Christopher M. O’Connor and Robert J. Mentz

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vol. 6 no. 4 298-307
DOI: 
https://doi.org/10.1016/j.jchf.2018.01.018
Published By: 
JACC: Heart Failure
Print ISSN: 
2213-1779
Online ISSN: 
2213-1787
History: 
  • Received October 8, 2017
  • Revision received January 21, 2018
  • Accepted January 23, 2018
  • Published online March 26, 2018.

Article Versions

Copyright & Usage: 
2018 American College of Cardiology Foundation

Author Information

  1. Lukasz P. Cerbin, MDa,∗ (lukasz.p.cerbin{at}duke.edu),
  2. Andrew P. Ambrosy, MDa,b,
  3. Stephen J. Greene, MDa,b,
  4. Paul W. Armstrong, MDc,
  5. Javed Butler, MDd,
  6. Adrian Coles, PhDb,
  7. Adam D. DeVore, MDa,b,
  8. Justin A. Ezekowitz, MDc,
  9. Adrian F. Hernandez, MDa,b,
  10. Marco Metra, MDe,
  11. Randall C. Starling, MDf,
  12. Wilson Tang, MDf,
  13. John R. Teerlink, MDg,
  14. Adriaan A. Voors, MDh,
  15. Angie Wu, BSb,
  16. Christopher M. O’Connor, MDi and
  17. Robert J. Mentz, MDa,b
  1. aDepartment of Internal Medicine, Duke University Medical Center, Durham, North Carolina
  2. bDuke Clinical Research Institute, North Carolina, Durham, North Carolina
  3. cCanadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
  4. dDivision of Cardiology, Stony Brook University, Stony Brook, New York
  5. eCardiology, University of Brescia, Brescia, Italy
  6. fHeart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
  7. gSection of Cardiology, San Francisco Veteran Affairs Medical Center, and School of Medicine, University of California-San Francisco, San Francisco, California
  8. hUniversity of Groningen, Groningen, the Netherlands
  9. iInova Heart and Vascular Institute, Falls Church, Virginia
  1. ↵∗Address for correspondence:
    Dr. Lukasz P. Cerbin, Department of Internal Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710.

Abstract

Objectives As the largest acute heart failure (AHF) trial conducted to date, the global ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial database presented an opportunity to systematically describe the relationship among time of hospital presentation, clinical profile, inpatient management, and outcomes among patients admitted with AHF.

Background Time of hospital presentation has been shown to impact outcomes among patients hospitalized with many conditions. However, the association among time of presentation and patient characteristics, management, and clinical outcomes among patients hospitalized with AHF has not been well characterized.

Methods A post hoc analysis of the ASCEND-HF trial was performed, which enrolled 7,141 patients hospitalized for AHF. Patients were divided based on when they presented to the hospital; regular hours were defined as 9 am to 5 pm, Monday through Friday, and off hours were defined as 5 pm to 9 am, Monday through Friday and weekends. Clinical characteristics and outcomes were compared by time of presentation.

Results Overall, 3,298 patients (46%) presented during off hours. Off-hour patients were more likely to have orthopnea (80% vs. 74%, respectively) and rales (56% vs. 49%, respectively) than regular-hour patients. Off-hour patients were more likely to receive intravenous (IV) nitroglycerin (18% vs. 11%, respectively) and IV loop diuretics (92% vs. 86%, respectively) as initial therapy and reported greater relief from dyspnea at 24 h (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.04 to 1.24; p = 0.01) than regular-hour patients. After adjustment, off-hour presentation was associated with significantly lower 30-day mortality (OR: 0.74; 95% CI: 0.57 to 0.96; p = 0.03) and 180-day mortality (hazard ratio [HR]: 0.82; 95% CI: 0.72 to 0.94; p = 0.01) but similar 30-day rehospitalization rates (p = 0.40).

Conclusions In this AHF trial, patients admitted during off hours exhibited a distinct clinical profile, experienced greater dyspnea relief, and had lower post-discharge mortality than regular-hour patients. These findings have implications for future AHF trials.

Key Words

Footnotes

  • The ASCEND-HF trial was supported by Scios Inc. Dr. Ambrosy is supported by National Heart, Lung, and Blood Institute (NHLBI) T32 post-doctoral training grant 5T32HL069749. Dr. Greene is supported by NHLBI T32 post-doctoral training grant 5T32HL069749-14 and a Heart Failure Society of America/Emergency Medicine Foundation Acute Heart Failure Young Investigator Award, funded by Novartis. Dr. Butler has received research support from U.S. National Institutes of Health (NIH), European Union, and Patient Centered Outcomes Research Institute; and is a compensated consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CardioCell, Janssen, Novartis, Relypsa, ZS Pharma, Medtronic, Merck, and CVRx. Dr. DeVore has received research funding from the American Heart Association, Amgen, and Novartis; and is a compensated consultant for Novartis. Dr. Ezekowitz is a compensated consultant for Pfizer, Abbott Laboratories, and Servier; and has received research support from Amgen and Johnson & Johnson. Dr. Hernandez is a compensated consultant for Sanofi, Johnson & Johnson, AstraZeneca, and Corthera; and has received research support from Amylin and Scios/Johnson & Johnson. Dr. Metra is a compensated consultant for Bayer, Novartis, and Servier. Dr. Starling is a compensated consultant for Novartis, BioControl, and Medtronic; and is owner/partner in CardioMEMS; has received research support from U.S. NIH, Medtronic, Biotronik, Novartis, and Thoratec; and has received honoraria from American Board of Internal Medicine. Dr. Teerlink has received research support and consulting fees from Amgen, Bayer, Bristol-Myers Squibb, Celyad, Cytokinetics, Johnson & Johnson, Medtronic, Novartis, Stealth, St. Jude, and Trevena. Dr. Voors is a compensated consultant for and has received research grants from Alere, Amgen, Bayer, Boehringer Ingelheim, Cardio3BioSciences, Celladon, GlaxoSmithKline, Merck Sharp and Dohme, Novartis, Servier, Singulex, Sphingotec, Stealth Peptides, Trevena, Vifor, and ZS Pharma. Dr. O’Connor is a compensated consultant for Novella and Amgen; is owner/partner in Biscardia, LLC; and has received research support from Otsuka, Roche Diagnostics, BG Medicine, Critical Diagnostics, Astellas, Gilead, GE Healthcare, and ResMed. Dr. Mentz has received research support from Amgen, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Gilead, Novartis, Otsuka, and ResMed; and has received honoraria from Thoratec. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

  • Barry H. Greenberg, MD, served as Guest Editor for this paper.

  • Received October 8, 2017.
  • Revision received January 21, 2018.
  • Accepted January 23, 2018.
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