The 18th Annual Scientific Meeting � HFSA S121

presenting features of the patients included LVAD power fluctuations (55%), acuteheart failure (26%), and dark urine (23%). Mean LDH level on admission was2,467 U/l (range: 490-10,670 U/l); 82% had a level of O 5,000 U/l. Notably,91% of these patients had an LDH levelO2,500 U/l one month prior to admission.Fifty-eight percent of the patients were noted to have subtherapeutic INR levelsbased on their preadmission target INR. Continuous heparin infusion was initiatedin 47 patients for an average duration of 11 days (range: 1-62 days). Surgicalpump exchange was deemed necessary in 12 patients; 3 received heart transplants,and 2 expired. On hospital discharge, aspirin dosage was increased in 7 patients; 2patients were started on clopidogrel. A total of 9 patients were readmitted after 30days; 8 for hemolysis, and 1 for acute heart failure. Conclusions: Elevations inLDH, and subtherapeutic INR levels are associated with increased risk of throm-botic events in LVAD patients. Moreover, marked elevations in LDH were de-tected one month prior to the events. Early detection of high-risk patients maybe feasible with improved outpatient monitoring, and earlier onset of treatmentmay preclude device exchange. Further chart review and data analysis arecurrently in progress for this study.

Figure.

313Heart Failure Readmissions: How Low Can You Go?Erin E. Berstler1, Lisa D. Rathman1, Christine E. Klingaman2, Justin D. Roberts1,Donna M. Fiorini1, Kelly A. Laino1, Kathleen M. Nissley1, Rhonda K. Price3,Tareck O. Nossuli1, Mark D. Etter1, Michael A. Horst4, Roy F. Small1; 1LancasterGeneral Health, Lancaster, PA; 2West Chester University, West Chester, PA;3Lancaster General Hospital, Lancaster, PA; 4Lancaster General Health, Lancaster,PA

Background: Reducing avoidable hospital readmissions is a national priority. It isimperative that hospitals develop methods to reduce avoidable heart failure (HF) re-admissions. While some readmissions may be potentially avoidable by improvingtransitions of care (TOC), others are probably not. The purpose of this retrospectivereview was to estimate how low the 30 day readmission rate might be in an optimallymanaged heart failure program. Methods: All patients discharged with a primarydiagnosis of heart failure between 1/1/2013 and 6/30/2013 were reviewed. Patientswere included in the readmission group if they were readmitted for any cause within30 days (CMS criteria). Readmissions were divided into two groups: potentiallyavoidable and unavoidable. Patients met criteria for potentially avoidable if clear def-icits in TOC which contributed to readmission and were potentially correctable. Re-sults: In a large community heart failure program, there were 630 HF admissions,104 readmissions in 88 patients. The mean age was 74.3611.8, with 51% males.The all cause readmission rate was 16%, with 46% readmitted for HF as a primarydiagnosis. 72 patients (82%) were readmitted 1 time, 13 patients (15%) readmitted2 times, 3 patients (3%) readmitted 3 times. Out of the 88 patients, 47% (50 outof 104 readmissions) were classified as potentially avoidable and 52% (54 out of104 readmissions) were classified as unavoidable. Conclusions: There is a theoreticallower limit to the readmission rate for HF patients. Coordinated and optimallymanaged HF programs may be able to reduce their readmission rates by nearlyhalf. This would represent a substantial improvement in current practices with asso-ciated cost savings which may justify the services required to achieve these results.

Table.

Cause of Readmission

Potentially Avoidable Unavoidable

Premature discharge New medical problem (GI bleeding,infection, non-syncopal fall, psychiatric,orthopedic injury, etc.)

Poor transition of care Intractable HF symptoms, despiteoptimum treatment

Inadequate follow-up End-stage HF without end of life carePatient non-adherenceInappropriate readmission

(pt who could have beenmanaged outpatient)

314Ambulatory Treatment of Heart Failure Decompensation by a MultidisciplinaryTeam Reduces Need for Hospital AdmissionLaura Burpee, Michelle Young, Cynthia Weiffenbach, Leo Buckley III, DanielleCarter, Judy Cheng, Irene Cooper, Lina Matta, Kristina Navarro-Velez, ElaineShea, Jennifer Smallwood, Craig Stevens, Joanne Weintraub, Lynne Stevenson,Akshay Desai; Brigham and Women’s Hospital, Boston, MA

Introduction: Efforts to prevent rehospitalization in heart failure (HF) patients havefocused on post-discharge care transitions, but provision of enhanced ambulatorysupports and treatment alternatives for those with worsening symptoms may alsobe important. Hypothesis: Short duration, ambulatory administration of intravenous

diuretics in an ambulatory care unit staffed by a nurse and a pharmacist will reducethe need for readmission in HF patients with recurrent decompensation. Methods:HF patients with signs and symptoms of congestion at rest sufficient to consider hos-pitalization were triaged by a specialized nurse practitioner for outpatient treatment.Suitable patients were given an intravenous bolus and continuous infusion of loop di-uretics for up to 3 hours in a monitored outpatient unit with dosing according to astandardized protocol. Education regarding self-management and detailed medicationreconciliation were provided by a nurse-pharmacist team. The primary efficacy out-comes were rates of hospital admission and symptom improvement at 30 days. Re-sults: The cohort included 60 patients with median age 70 years of whom 57% weremale, 25% were non-white, and 60% had EFO550%. Over 114 separate encounters,the median change in weight at 24 hours was -1.1 kg (IQR -1.9, -0.2), and 57% re-ported improved breathing, 66% reported feeling better overall. Global symptomimprovement was sustained to 30 days in 62% (Figure). While hospitalization wasconsidered imminent in 51% of patients at the time of referral, only 33% were actu-ally hospitalized by 30 days, representing 11 potential hospitalizations averted. Con-clusions: Short duration, ambulatory diuretic infusion with enhanced education bypharmacists and nurses reduced the need for hospital admission and improvedwell-being at 30 days in HF patients with worsening symptoms.

315Protective Role of Medications on Atrial Fibrillation and Heart Failure withPreserved Ejection FractionArnav Kumar1, Amarpreet K. Saluja2, Adnan Khan1, Mohammad Morsy3, Wissam I.Khalife3; 1UTMB, Galveston, TX; 2UTMB, Galveston, TX; 3UTMB, Galveston, TX

Background: Arial Fibrillation (AFib) is being increasingly recognized as associatedto heart failure with preserved ejection fraction (HFpEF). Large studies examiningthe impact of medications on this association have been lacking. Methods: In across-sectional study, we reviewed the medical records and echocardiographic char-acteristics of patients who presented to the echo lab in a tertiary care academic centerbetween 2008 and 2011. Patients were said to have HFpEF if they had EF $50%,history of CHF according to Framingham criteria and were NYHA II or above fora period of three months. Using logistic regression analysis the impact of AFib onHFpEF was assessed after adjusting for potential clinical and demographic con-founders. Then, we hypothesized that medications (i.e. angiotensin convertingenzyme inhibitors [ACE-inh]/ Angiotensin II receptor blockers [ARB], statins, betablockers, diuretics or any combination of these) might modify this association andexamined the interaction term of medications in regards to the association betweenAFib and HFpEF. Results: Among 2443 patients, 420 patients (17.1%) had HFpEF.Atrial fibrillation (AFib) was found in 187 patients (7.6%). Among patients withHFpEF, 62(14.7%) had AFib. Logistic regression analysis showed that that patientswith Atrial Fibrillation were 2.6 times more likely to develop HFpEF (OR 5 2.6,p ! 0.001). Those who had AFib and were not taking ACE-inh/ARB, Beta-blockers,Statins, or any combination of these were more likely to develop HFpEF (OR5 3.72,3.76, 3.56 respectively, p ! 0.0001). Conclusion: Our study indicates a clear asso-ciation between AFib and HFpEF. Also ACE-inh/ARB, statins and beta-blockersalone or in combination can play a protective role in development of HFpEF amongpatients with AFib.

316Specialized Exercise Prescription Program on Quality of Life and FunctionalCapacity with Heart Failure: Lessons LearnedCharlene Whitaker-Brown1, Sanjeev Gulati2, Debbie Fenner3, Mike Lippard4,Amanda Thompson5, Stephanie Woods1; 1University of North Carolina atCharlotte, Charlotte, NC; 2Carolinas Health Care System, Charlotte, NC;3Carolinas Health Care System, Charlotte, NC; 4Carolinas Health Care System,Concord, NC; 5Carolinas Health Care System, Concord, NC

Purpose: The purpose of this project was to examine differences on quality of life(QOL) and functional capacity in persons participating in a multidisciplinary 4-