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Analysis

How Hospitals Can Avoid Broken Heart Syndrome Readmissions

By Christopher Cheney  
   October 08, 2018

Nearly 12% of Takotsubo Syndrome patients are readmitted to a hospital within 30 days of an inpatient stay, recent research shows.

Patients are far less likely to die from broken heart syndrome than they are to die from a heart attack, but that doesn't mean providers can safely ignore the risks associated with the less-severe condition.

Patients diagnosed with broken heart syndrome, or Takotsubo Syndrome (TTS), still face a significant risk of hospital readmission, recent research shows.

"Two thirds of the hospital readmissions within 30-days of TTS occurred in the first two weeks post-discharge, highlighting the need for careful follow-up in these vulnerable patients," researchers wrote this month in an article published in the European Heart Journal—Quality of Care and Clinical Outcomes.

The research compares TTS to acute myocardial infarction (AMI) for measures including predictors, readmissions, mortality, and cardiovascular risk factors.

Broken heart syndrome features transient left ventricular dysfunction with symptoms and electrocardiography results that mimic heart attack, the researchers wrote.

There are about 12,000 cases of TTS each year, accounting for 1-2% of all acute coronary syndromes, according to lead author Nathaniel Smilowitz, MD, an assistant professor at the New York University School of Medicine.

Mortality for broken heart syndrome is much lower than that for a heart attack. During a first admission for TTS, mortality was 2.3%, while the mortality rate for acute myocardial infarction admissions was 10.2%, according to the research.

Despite the lower mortality rate, broken heart syndrome poses a significant risk for readmission—which carries potential health risks for patients and possible financial penalties for providers.

Health and financial risks
 

Among TTS survivors, 11.9% were readmitted within 30 days, and mortality associated with readmission was 3.5%, the researchers found. The most common readmission cause was heart failure at 10.6% of readmissions.

Among the heart attack survivors in the study, 16.7% were readmitted within 30 days.

For TTS survivors, the researchers found age, malignancy, peripheral vascular disorders, chronic lung disease, heart failure, drug abuse, and anemia were predictors of 30-day hospital readmissions.

Although broken heart syndrome is not one of the conditions listed under Medicare's Hospital Readmissions Reduction Program, some broken heart syndrome cases are likely drawing HRRP penalties, Smilowitz told HealthLeaders.

"These patients may be improperly diagnosed with myocardial infarction, and myocardial infarction readmissions are subject to penalties in HRRP. Therefore, hospital readmissions for the proportion of TTS patients who are assigned AMI diagnosis codes may contribute to penalties under HRRP," he said.

More research is needed to optimize treatment of TTS in the inpatient setting and post-discharge, but there are indicated treatments and guidance for follow-up care, Smilowitz said.

"The care of Takotsubo Syndrome in the acute setting depends on the clinical presentation, the severity of left ventricular dysfunction, and the presence of left ventricular outflow tract obstruction or shock. There are unfortunately no randomized clinical trials guiding the treatment of Takotsubo patients, but large observational studies have indicated better long-term outcomes among Takotsubo patients treated with ACE inhibitors," he said.

Monitoring TTS patients after discharge is essential to avoid readmissions, Smilowitz said.

"Our study shows that heart failure may complicate Takotsubo Syndrome in the near term, so we now recommend close follow up after discharge to evaluate for signs and symptoms of heart failure, which can be treated appropriately with medical therapy such as diuretics."

Characteristics and predictors
 

The researchers found several distinguishing characteristics and predictors for broken heart syndrome compared to heart attack:

  • TTS patients were more often to be women (89%) compared to female heart attack patients (41%)
     
  • Cardiovascular complications were less common during a first admission for TTS patients compared to AMI patients. For example, 2.7% of TTS patients experienced cardiac arrest compared to 4.4% of AMI patients.
     
  • TTS patients were younger and more likely to have a history of depression, psychosis, alcohol or drug abuse, hypothyroidism, rheumatoid arthritis, collagen vascular disease, and chronic pulmonary disease than AMI patients.

There are important distinctions between patients with broken heart syndrome and heart attack patients, the researchers wrote.

"Patients with TTS had a lower incidence of underlying cardiovascular risk factors and established cardiovascular disease than patients with AMI. In contrast, TTS patients were more likely to have psychiatric disease diagnoses in comparison to patients with AMI," they wrote.

Mortality rates are lower for broken heart syndrome compared to heart attack, but TTS is a deadly condition, the researchers wrote.

"Although outcomes of TTS appear favorable when compared to acute MI, patients with TTS have a substantial risk of in-hospital death and 30-day readmission among survivors. Thus, TTS is associated with morbidity and mortality in thousands of patients in the U.S. each year."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Broken heart syndrome mimics acute myocardial infarction symptoms such as abnormal electrocardiography results.

Mortality rates are about four times higher for AMI compared to broken heart syndrome, recent research shows.

Among broken heart syndrome patients readmitted to hospitals, the mortality rate is 3.5%.


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