BACKGROUND: Heart failure (HF) is one of the leading causes of morbidity and mortality among Americans. Despite increased interest in end-of-life care, the implications of do-not-resuscitate (DNR) orders in acutely ill patients with HF remain unclear. The goals of this observational study were to describe the use of DNR orders and their impact on treatment approaches in residents of a large New England metropolitan area hospitalized with acute heart failure. METHODS: Use of HF performance measures, including assessment of left ventricular function, use of angiotensin receptor blocking agents, anticoagulation, smoking cessation counseling, and use of nonpharmacologic strategies, was examined through review of the medical records of 4,537 metropolitan Worcester (MA) residents admitted to 11 central Massachusetts hospitals with acute HF in 1995 and 2000 according to the presence of DNR orders. RESULTS: Patients with DNR orders were less likely to have had their left ventricular function assessed (31% vs 43%) as well as receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%) as compared to patients without DNR orders. Patients with DNR orders were significantly less likely to have received any quality assurance measure for acute HF (adjusted hazard ratio 0.63, 95% confidence interval 0.40-0.99) than patients without DNR orders. CONCLUSIONS: The use of quality assurance measures in acute HF is markedly lower in patients with DNR orders. The implications of DNR orders need to be further clarified in the treatment of patients with acute HF.

BACKGROUND: Patients with kidney disease are at increased risk for adverse health outcomes in comparison to patients without kidney disease. Therefore, patients with kidney disease may have greater use of do-not-resuscitate (DNR) orders than patients without kidney disease in the setting of an acute illness. We examined the association between advanced kidney disease and use of DNR orders in patients admitted with an acute myocardial infarction (AMI) to all greater Worcester, MA, hospitals as part of an epidemiological study. METHODS: Use of DNR orders in 4,033 Worcester residents hospitalized with AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003 was examined. Advanced kidney disease was defined on the basis of serum creatinine level at the time of hospital admission. RESULTS: Forty-nine percent of patients with kidney disease and AMI had a DNR order in their medical records compared with 21% of patients without kidney disease. After controlling for a variety of potentially confounding factors, patients with kidney disease were more likely to have a DNR order than patients without kidney disease (adjusted odds ratio, 1.55; 95% confidence interval, 1.21 to 1.98). Patients with advanced kidney disease who received DNR orders were older, had more comorbid conditions, and were at greater risk for dying than patients with kidney disease without a DNR order. CONCLUSION: Advanced kidney disease is associated with greater rates of DNR orders in patients hospitalized with AMI. Awareness of kidney disease may be an important consideration for patients and health care providers in discussing the use of DNR measures.

BACKGROUND: Patients seeking care for acute myocardial infarction (AMI) present with multiple symptoms. The objectives of our community-wide study are to examine the symptom profile of patients with, as compared with those without, kidney disease who present to the hospital with independently confirmed AMI. METHODS: The symptom profile of 4,482 patients from the Worcester, MA, metropolitan area hospitalized with independently validated AMI at all 11 area medical centers during the 4 study years of 1997, 1999, 2001, and 2003 was examined. Factor analysis was used to aggregate the relevant symptoms of AMI. Logistic regression analysis was used to examine differences in symptoms of AMI according to the presence of kidney disease while controlling for several potentially confounding demographic and clinical factors. RESULTS: Patients with kidney disease were less likely to report chest pain (adjusted odds ratio, 0.57; 95% confidence interval, 0.46 to 0.70), arm pain (odds ratio, 0.52; 95% confidence interval, 0.42 to 0.64), shoulder pain (odds ratio, 0.53; 95% confidence interval, 0.40 to 0.72), or neck pain (odds ratio, 0.54; 95% confidence interval, 0.41 to 0.70), while being more likely to report shortness of breath (odds ratio, 1.35; 95% confidence interval, 1.13 to 1.62), in comparison to patients without kidney disease in the setting of AMI. CONCLUSION: Kidney disease impacts on the manner in which patients present with AMI. Although patients with kidney disease are at known increased risk for several diseases, this study suggests that kidney disease also might change how these patients experience these diseases, including acute coronary disease.