Impact of integrated care in patients with heart failure with reduced ejection fraction: a report from the WARCEF trial

Abstract

Abstract Background In recent years there has been more and more attention to the concept of ‘integrated care’ for patients with cardiovascular diseases. Integrated care strategies have been thought to provide comprehensive evaluation and management of patients characterized by complex chronic conditions and high prevalence of comorbidities. Purpose To propose and evaluate an integrated care management for patients with heart failure with reduced ejection fraction (HFrEF). Methods We performed a secondary analysis of the WARCEF trial, which randomized HFrEF patients with sinus rhythm at baseline to Warfarin and Aspirin. We propose the ABC-HF as a strategy of integrated care management. ABC-HF stands on three pillars: i) Adherence to Guideline-Directed-Medical-Therapy, defined as ACE inhibitors/ARBs plus Beta-Blockers plus MRAs; ii) Better symptom control, defined as NYHA category I-II; iii) Comorbidities optimisation, as per guideline-directed management of hypertension, previous myocardial infarction, previous stroke, peripheral vascular disease, (incident) atrial fibrillation, etc. Patients were managed adherent to the ABC-HF strategy if all the three conditions were fulfilled. Main outcome was the composite of ischemic stroke, intracranial hemorrhage, all-cause death. Results A total of 2,264 patients were available for analysis (mean [SD] age 60.8 [11.4] years, 450 [19.9%] females). Overall, 254 (11.2%) patients were managed adherent to ABC-HF: 199 (8.8%) adherent to no criteria; 905 (40.0%) to one criterion; and 906 (40.0%) to two criteria. Over a mean (SD) follow-up of 3.55 (1.78) years there were 602 (26.6%) events. Patients managed adherent to ABC-HF reported a lower rate of composite outcome compared to those non-adherent (16.1% vs. 27.9%, p<0.001). A Cox multivariate regression analysis adjusted for age, sex, ejection fraction, randomized treatment, and Minnesota physical domain score showed that clinical management adherent to ABC-HF was associated with a reduction in the risk of the primary composite outcome (HR 0.54, 95% CI 0.38-0.76). A progressively higher number of ABC-HF criteria fulfilled was associated with a progressively lower risk [Figure 1]. Conclusion In a cohort of HFrEF with severe ventricular dysfunction, adherence to ABC-HF, as an integrated care management for HF patients, is associated with a lower risk of adverse outcomes. Higher numbers of ABC-HF criteria fulfilled is associated with a progressively lower risk.ABC-HF Criteria and Risk of Composite Ou