Longer-than-average length of stay in acute heart failure : Determinants and outcomes

Increased length of stay (LOS) during acute heart failure (HF) hospitalization is associated with readmission and mortality.

The ESCAPE trial data were utilized to identify determinants and post-discharge outcomes of patients with acute systolic HF requiring longer-than-average LOS (≥7 days). The study endpoints were 6‑month all-cause mortality, all-cause rehospitalization, and the composite endpoint of death, cardiac rehospitalization, and cardiac transplant.

Among the 424 patients with recorded LOS, 216 (50.9%) and 208 (49.1%) had LOS ≥ or <7 days, respectively. Independent determinants of longer-than-average LOS included older age (OR per 10-year increase: 1.759, 95% CI: 1.120-2.763, p = 0.014), higher blood urea nitrogen (OR per 5 mg/dl increase: 1.202, 95% CI: 1.024-1.410, p = 0.024), greater inferior vena cava diameter (OR per 1 cm increase: 2.453, 95% CI: 1.175-5.121, p = 0.017), and lower sodium (OR per 4 mmol/l increase: 0.494, 95% CI: 0.268-0.911, p = 0.024). We found a significant correlation between right-sided failure (right atrial pressure) and LOS (r = 0.229, p = 0.001) but not left-sided failure (pulmonary capillary wedge pressure, r = 0.099, p = 0.177). Patients with longer-than-average LOS had a significantly higher mortality (25.9% vs. 12%, univariate OR: 2.562, 95% CI: 1.528-4.296, p < 0.001), higher all-cause rehospitalization (63% vs. 53.4%, univariate OR: 1.486, 95% CI: 1.008-2.190, p = 0.046) and higher frequency of the composite endpoint of death, cardiac rehospitalization, and cardiac transplant (61.6% vs. 45.2%, univariate OR: 1.943, 95% CI: 1.320-2.862, p = 0.001) compared with an LOS of <7 days. Cox proportional hazard analysis showed that a longer-than-average LOS was an independent predictor of 6‑month all-cause mortality (HR: 1.930, 95% CI: 1.112-3.350, p = 0.019).

In acute HF, right ventricular failure and renal dysfunction predict longer-than-average LOS, which is a proxy for more severe HF and is associated with worse postdischarge outcomes.