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Limited data exist on the epidemiology, evaluation, and prognosis of otherwise unexplained anaemia of the elderly in heart failure (HF). Thus, we aimed to determine the incidence of anaemia, to characterize diagnostic testing patterns for potentially reversible causes of anaemia, and to evaluate the independent association between incident anaemia and long-term morbidity and mortality.

IMPORTANCE: Chronic kidney disease (CKD) is common in adults with heart failure and is associated with an increased risk of sudden cardiac death. Randomized trials of participants without CKD have demonstrated that implantable cardioverter defibrillators (ICDs) decrease the risk of arrhythmic death in selected patients with reduced left ventricular ejection fraction (LVEF) heart failure. However, whether ICDs improve clinical outcomes in patients with CKD is not well elucidated. OBJECTIVE: To examine the association of primary prevention ICDs with risk of death and hospitalization in a community-based population of potentially ICD-eligible patients who had heart failure with reduced LVEF and CKD. DESIGN, SETTINGS, AND PARTICIPANTS: This noninterventional cohort study included adults with heart failure and an LVEF of 40% or less and measures of serum creatinine levels available from January 1, 2005, through December 31, 2012, who were enrolled in 4 Kaiser Permanente health care delivery systems. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2. Patients who received and did not receive an ICD were matched (1:3) on CKD status, age, and high-dimensional propensity score to receive an ICD. Follow-up was completed on December 31, 2013. Data were analyzed from 2015 to 2017. EXPOSURES: Placement of an ICD. MAIN OUTCOMES AND MEASURES: All-cause death, hospitalizations due to heart failure, and any-cause hospitalizations. RESULTS: A total of 5877 matched eligible adults with CKD (1556 with an ICD and 4321 without an ICD) were identified (4049 men [68.9%] and 1828 women [31.1%]; mean [SD] age, 72.9 [8.2] years). In models adjusted for demographics, comorbidity, and cardiovascular medication use, no difference was found in all-cause mortality between patients with CKD in the ICD vs non-ICD groups (adjusted hazard ratio, 0.96; 95% CI, 0.87-1.06). However, ICD placement was associated with increased risk of subsequent hospitalization due to heart failure (adjusted relative risk, 1.49; 95% CI, 1.33-1.60) and any-cause hospitalization (adjusted relative risk, 1.25; 95% CI, 1.20-1.30) among patients with CKD. CONCLUSIONS AND RELEVANCE: In a large, contemporary, noninterventional study of community-based patients with heart failure and CKD, ICD placement was not significantly associated with improved survival but was associated with increased risk for subsequent hospitalization due to heart failure and all-cause hospitalization. The potential risks and benefits of ICDs should be carefully considered in patients with heart failure and CKD.

ObjectivePatients with chronic kidney disease (CKD) have higher risk of sudden cardiac death; however, they may not receive implantable cardioverter defibrillators (ICDs), in part due to higher risk of complications. We evaluated whether CKD is associated with greater risk of device-delivered shocks/antitachycardia pacing (ATP) therapies among patients receiving a primary prevention ICD.MethodsWe studied participants in the observational Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Outcomes included all delivered shocks/ATPs therapies and type of shock/ATP therapies (inappropriate or appropriate, determined by physician adjudication) within the 3 years. We evaluated the associations between CKD and time to first device therapy, burden of device therapy, and inappropriate versus appropriate device therapy, adjusting for demographics, comorbidity, laboratory values and medication use.ResultsAmong 2161 participants, 1066 (49.3%) had CKD (eGFR 44±11 mL/min/1.73 m2) at ICD implantation. During mean of 2.26±0.89 years, 9.8% and 18.5% of participants had at least one inappropriate and appropriate shock/ATP therapies, respectively. CKD was not associated with time to first shock/ATP therapies (adjusted HR 0.87, 95% CI 0.73 to 1.05), overall burden of shock/ATP therapies (adjusted relative rate 0.93, 95% CI 0.74 to 1.17) or inappropriate versus appropriate shock/ATP therapies (adjusted relative risk 0.88, 95% CI 0.68 to 1.14) compared with not having CKD.ConclusionsIn adults receiving a primary prevention ICD, mild-to-moderate CKD was not associated with the timing, burden or appropriateness of subsequent device therapy. Potential concern for inappropriate ICD-delivered therapies should not preclude ICDs among eligible patients with CKD.

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Systematic case identification is critical to improving population health, but widely used diagnosis code-based approaches for conditions like valvular heart disease are inaccurate and lack specificity.

Limited existing data suggest that the novel COVID-19 may increase risk of VTE, but information from large, ethnically diverse populations with appropriate control participants is lacking.

Multiple morbidity is the norm in advanced COPD and contributes to high symptom burden and worse outcomes.

Introduction:Heart failure (HF)-related hospitalizations are a growing public health burden. We evaluated two published risk calculators for predicting 30-day readmission after HF hospitalizations: 1) using the original coefficients, 2) updating the coefficients 3) developing a new model with additional variables and updated coefficients.Hypothesis:Recalibrating model coefficients and adding variables would improve the performance of existing 30-day readmission risk calculators.Methods:We identified 45,059 adults hospitalized for HF between 2012-2017 within Kaiser Permanente Northern California, an integrated healthcare delivery system. We used split sampling for development and validation testing. The risk calculators tested included: LACE+ Index and Yale CORE. We used logistic regression on our population to derive the recalibrated coefficients. For the model with additional variables, we included all variables used in the original models plus additional variables, including cardiovascular medication use and socioeconomic status. We used gradient boosting with k-fold cross validation to avoid overfitting. We assessed model performance using area under the curve (AUC) and calibration plots.Results:Discrimination (AUC) was poor using original models: LACE+ [0.56 (0.54-0.58)] and Yale CORE [0.55 (0.54-0.57)]. Recalibrating coefficients resulted in small improvements for LACE+ [0.58 (0.57, 0.60)] and Yale CORE [0.58 (0.57, 0.60)]. Adding variables resulted in a modest improvement for the gradient boosting model [0.61 (0.59, 0.62)]. Calibration plots (Figure 1) showed good calibration except for the Yale CORE model with the original coefficients.Conclusions:Recalibrating coefficients and incorporating prior medication and socioeconomic status led to modest, significant improvements in discrimination while maintaining good calibration. However, overall performance improvements are needed to increase the utility of these published risk calculators to predict readmission.

Introduction:Administrative claims data are often used for population management and quality reporting, but diagnosis codes for conditions such as valvular heart disease can be inaccurate and vary across health systems. Echocardiography (echo) data contain detailed clinical information but are generally unstructured and not feasible to extract manually in large scale.Methods:We developed and validated natural language processing (NLP) algorithms to identify aortic stenosis (AS) from echo reports in Kaiser Permanente Northern California (KPNC) and compared AS identification using NLP vs. administrative codes. Using NLP software (Linguamatics i2e), we initially developed algorithms to identify AS from a development set of >100 echo reports manually confirmed with AS, with iterative refinement using additional development sets (>100 echo reports each) until the NLP algorithm achieved positive and negative predictive values (PPV and NPV) of >95%. We then applied the NLP algorithm to all 2008-2018 echo reports (transthoracic, transesophageal or stress) in KPNC adults and compared results to ICD-9/10 diagnostic code-based definitions from 14 days before to 6 months after the echo date.Results:The NLP algorithm was developed and refined among >500 echo reports to achieve >95% PPV and NPV. Application of NLP to 957,505 echo reports (N=522,653 patients with mean age 63.3 years, 51% women, 8.5% black, 13.5% Asian/Pacific Islander, 12.9% Hispanic and median [interquartile range] 1 [1 to 2] echoes per person) yielded 104,090 echoes (10.9%) with AS (N=53,791 patients). Among echoes identified by NLP as positive for AS, 36,070 (34.7%) had diagnosis codes for AS between 14 days prior and 6 months after echo. Among echo?s without AS via NLP, 12,626 (1.5%) had diagnosis codes for AS between 14 days before to 6 months after the echo.Conclusions:An NLP algorithm applied to a large echo database was more accurate than using diagnosis codes for identifying AS and can facilitate more effective individual and population management than relying on administrative data alone. Future NLP development to characterize AS severity will further advance personalized and population-based care strategies for surveillance and treatment.

Introduction:Iron deficiency is common but infrequently tested for among older adults with heart failure (HF) and anemia. A low transferrin saturation (TSAT) and/or a reduced ferritin are suggestive of iron deficiency, but plasma concentrations of these proteins may be altered in response to inflammation and confound their interpretation in the setting of HF.Methods:We identified a multicenter cohort of adults age ?65 years with HF and incident anemia (hemoglobin <13 g/dL [men] or <12 g/dL [women]) between 2005-2012. Participants were required to have ferritin (ng/mL) and TSAT (%) evaluated within 90 days. Outcomes were ascertained from electronic health records.Results:Among 4,103 older adults with HF, incident anemia, and iron studies, 47% had TSAT <20% and median (IQR) ferritin was 126 (52.5, 256.0) ng/mL. Crude rates of HF hospitalization (Figure A) and all-cause death (Figure B) were higher for participants with a TSAT <20% vs. TSAT ?20% at any ferritin level. After adjustment for demographics, medical history, kidney function, proteinuria and medications, patients with TSAT <20% vs. TSAT ?20% were at increased risk of HF hospitalization for a corresponding ferritin <100 ng/mL (adjusted HR [aHR] 1.42, 95% CI 1.18-1.71) or 100-300 ng/mL (aHR 1.31, 95%CI:1.08-1.59). TSAT <20% (vs. >20%) was independently associated with an increased risk of death from any cause irrespective of baseline ferritin (<100 ng/mL: aHR 1.46, 95%CI:1.24-1.70; 100-300 ng/mL: aHR 1.21, 95%CI:1.03-1.42; >300 ng/mL: aHR 1.38, 95%CI:1.10-1.74).Conclusions:Among older adults with HF and incident anemia who had iron studies, ~50% had a TSAT <20%, which independently correlated with higher rates of morbidity and mortality across a wide range of ferritin levels. Additional research is required to clarify the role of routine evaluation and treatment of functional iron deficiency (impaired mobilization) based on an isolated low TSAT.