Reduction of Hospitalization and Mortality by Echocardiography-Guided Treatment in Advanced Heart Failure.

Hamayak Sisakian,Sergey Pepoyan,Ashkhen Maghaqelyan,Syuzanna Shahnazaryan,Sona Melik-Stepanyan,Mariam Hovhannisyan,Armine Minasyan,Yury Lopatin,Armine Chopikyan,Gor Martirosyan

doi:10.3390/jcdd9030074

Abstract

In advanced heart failure (AHF) clinical evaluation fails to detect subclinical HF deterioration in outpatient settings. The aim of the study was to determine whether the strategy of intensive outpatient echocardiographic monitoring, followed by treatment modification, reduces mortality and re-hospitalizations at 12 months. Methods: 214 patients with ejection fraction < 30% and >1 hospitalization during the last year underwent clinical evaluation and echocardiography at discharge and were divided into intensive (IMG; N = 143) or standard monitoring group (SMG; N = 71). In IMG, volemic status and left ventricular filling pressure were assessed 14, 30, 90, 180 and 365 days after discharge. HF treatment, particularly diuretic therapy, was temporarily intensified when HF deterioration signs and E/e’ > 15 were detected. In SMG, standard outpatient monitoring without obligatory echocardiography at outpatient visits was performed. Results: We observed lower hospitalization (absolute risk reduction [ARR]-0.343, CI-95%: 0.287–0.434, p < 0.05; number needed to treat [NNT]-2.91) and mortality (ARR-0.159, CI 95%: 0.127–0.224, p < 0.05; NNT-6.29) in IMG at 12 months. One-year survival was 88.8% in IMG and 71.8% in SMG (p < 0.05). Conclusion: In AHF, outpatient monitoring of volemic status and intracardiac filling pressures to individualize treatment may potentially reduce hospitalizations and mortality at 12 months follow-up. Echocardiography-guided outpatient therapy is feasible and clinically beneficial, providing evidence for the larger application of this approach.

Highlights

Advanced heart failure (AHF) is a clinical syndrome characterized by persistent heart failure (HF) symptoms and progressive left ventricular (LV) dysfunction, despite guidelinebased medical therapy [1–4]
Eligibility criteria for intensive outpatient echo-guided monitoring included: (1) age between 18 and 90 years, (2) symptomatic patients with NYHA III–IV functional class, despite the optimal guideline-based therapy, (3) more than 1 hospitalization for HF decompensation within the past 12 months, (4) LV ejection fraction (EF) < 30% documented by transthoracic echocardiography, (5) left atrial (LA) volume > 35 mL/m2, and (6) E/e’ > 15 determined by Tissue Doppler (TD) before hospital discharge
It has become evident that ambulatory monitoring of patients with HF leads to fewer decompensations

Summary

Introduction

Advanced heart failure (AHF) is a clinical syndrome characterized by persistent heart failure (HF) symptoms and progressive left ventricular (LV) dysfunction, despite guidelinebased medical therapy [1–4]. Patients with advanced progressive HF have frequent hospital readmissions due to pulmonary or systemic congestion, high mortality and poor quality of life [2,3]. Progressive dyspnoea, weight gain, peripheral oedema and crackles on lung auscultation are suggestive of HF deterioration and are important predictors of the upcoming HF decompensation and hospitalization [6]. Intracardiac hemodynamic changes and an increase in LV filling pressure precede the manifestation of HF symptoms and can be detected by echocardiography [10–12]. Increased ventricular filling pressure results in high atrial pressure with subclinical HF deterioration [13,14]. The possibility to assess filling pressure in ambulatory patients with AHF provides accurate diagnosis of subclinical decompensation, expanding the already established role of echocardiography in heart failure. Identification of the vulnerable period is important for the timely adjustment of a therapeutic regimen to prevent HF decompensation-related rehospitalizations in AHF patients

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