Dedicated Heart Failure Clinic Research Articles

The impact of a dedicated heart failure clinic on patients with heart failure with reduced ejection fraction

Abstract Introduction Heart failure (HF) is not a diagnosis but rather a syndrome with a variety of potential causes and once a patient has been diagnosed as having HF, the underlying etiology should be sought and treated. Thus, patients with HF should be engaged in a disease management program that includes a dedicated wider healthcare team which is critical for delivering the best care for patients. A dedicated HF clinic is one of the cornerstones of this ultimate management program. This clinic is specifically made to make sure of the proper management and follow-up of those patients. There is a scarce evidence of weather a dedicated HF clinic can alter the long-term outcomes of HF patients or not. Thus, the aim of this study is to search for the impact of a dedicated HF clinic on patients with HF with reduced ejection fraction (HFrEF) regarding the symptoms, management received according to latest guidelines, the patients’ quality of life and impact on health care resources. Patients and Methods This is a single center retrospective study that included patients presented to a dedicated heart failure clinic at a secondary care hospital through a one-year period. The study group included patients with diagnosis of HFrEF only who had one or more visit to the HF clinic. These patients served as their own control. Hospital admissions and emergency room visits in the 12-month period preceding enrollment was compared to the number in the following year after enrollment. Patients with incomplete data and those with ejection fraction >40% were excluded. Results The study included 48 patients with a mean age of 65 years, 70.8% of them were males. Most of the patients were hypertensive (77.1%), diabetic (75%) and with history of coronary artery disease (60.4%). Symptoms improved significantly in all patients, left ventricular volumes and ejection fraction improved (31±8.1% vs 40.7±10.5%) (P<0.0001). NT-ProBNP level improved significantly (5927 ng/L vs 3135 ng/L) (P = 0.03). The guideline directed medical therapy was used properly before and after the clinic. There was a significant improvement in the quality of life where the KCCQ-12 score improved from 71.25±13.2 to 83.3±13.3 (P<0.0001), six-minute walk test also improved significantly from 362±184 meters to 479±211 meters (P = 0.005). Regarding the economic impact, there was no significant difference in the number of unplanned visits (20.8% vs 10.4%) (P = 0.16) but there was a significant reduction in the number of HF hospitalizations within one year (20.8% vs 6.25%) (P = 0.038) Conclusion Dedicated HF clinics are very important now for the proper management of HF patients where it is proved that it can improve HF symptoms, improve the quality of life measurements, maintain the proper guideline directed therapy and reduce the economic burden of HF through reducing the number of HF hospitalizations.Clinical dataOutcomes

The Changing Face of Chronic Heart Failure: An 8-Year Study in a Real-World Setting

Over the past decade, treatment of heart failure with reduced ejection fraction has changed dramatically. We compared patient demographics and outcomes at a dedicated heart failure clinic in a non-tertiary centre through a snapshot audit conducted in 2013 and 2020/21.

How to develop a national heart failure clinics network: a consensus document of the Hellenic Heart Failure Association.

Heart failure (HF) is rapidly growing, conferring considerable mortality, morbidity, and costs. Dedicated HF clinics improve patient outcomes, and the development of a national HF clinics network aims at addressing this need at national level. Such a network should respect the existing health care infrastructures, and according to the capacities of hosting facilities, it can be organized into three levels. Establishing the continuous communication and interaction among the components of the network is crucial, while supportive actions that can enhance its efficiency include involvement of multidisciplinary health care professionals, use of structured HF‐specific documents, such as discharge notes, patient information leaflets, and patient booklets, and implementation of an HF‐specific electronic health care record and database platform.

P3547Real world experience of sacubitril/valsartan: insights on tolerability and outcome from a specialised heart failure clinic

Abstract Background Sacubitril/Valsartan has been shown to improve symptoms and outcomes in patients with heart failure (HF) reduced ejection fraction in a single large randomised controlled trial. However, real-world data on its effect is limited. Purpose Our centre operates a dedicated HF clinic for the initiation and titration of Sacubitril/Valsartan in suitable patients. We report on patient tolerability and incidence of adverse effects. We also assessed change in New York Heart Association (NYHA) class and left ventricular ejection fraction (LVEF) post-treatment, as well as HF hospitalisation and mortality at 6 months. Methods We conducted a retrospective review of all patients seen in the clinic between January 2016 to January 2019. Patient demographics and pre-initiation treatments were recorded. We compared NYHA class and LVEF category as measured by echocardiography, at initiation and post-titration to the maximum tolerated dose. Data on HF admissions were obtained from electronic hospital records and mortality from a national database. Results A total of 179 patients were initiated on Sacubitril/Valsartan and included in the study. Mean age was 71 years (41–90), and 138 (77%) were male. Half of the patient cohort (89) had an ischaemic aetiology. Prior to initiation, all patients were established on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Almost all were on a beta-blocker (99%) and mineralocorticoid receptor antagonist (98%). 56 patients (31%) had a Cardiac Resynchronisation Therapy (CRT) device and 31 (17%) had an Implantable Cardioverter-Defibrillator (ICD). Only 4 patients (2%) had to discontinue treatment completely due to an adverse reaction. Among them, 3 patients sustained an acute kidney injury (AKI) while 1 patient had increased breathlessness. 40 patients (22%) reported symptomatic hypotension which required dose reduction. 7 patients (4%) sustained an AKI. 2 patients reported a rash and 1 patient reported nausea. Figure 1 shows the change in NYHA class after establishment on Sacubitril/Valsartan. Data on change in LVEF post establishment of Sacubitril/Valsartan was available in 124 patients and is shown in figure 2. A total of 133 patients had completed titration of treatment by July 2018 and included in the analysis of 6-month outcome. 13 patients had one HF hospitalisation and all-cause mortality was 4.5% (6 patients). Only 1 patient had heart failure documented as the primary cause of death. Change in NYHA class and LVEF Conclusion In our cohort of well treated HF patients with reduced ejection fraction, 40% of patients experienced an improvement in NYHA class after establishment on Sacubitril/Valsartan while 35% of patients also experienced a significant improvement in LVEF. Treatment was well tolerated and the discontinuation rate was low when managed in a dedicated HF clinic focused on initiation of Sacubitril/Valsartan.

The Impact of a Dedicated Heart Failure (HF) Clinic on Hospitalization Rates, Hospitalization Costs, and Left Ventricular Ejection Fraction (LVEF) in Systolic Heart Failure Patients

IntroductionHeart failure with reduced ejection fraction (HFrEF) is one of the most costly conditions with high morbidity and mortality. There is still paucity of data for cost-effective outpatient heart failure (HF) management. In an effort to prevent hospital admissions and morbidity, the focus has shifted toward effective outpatient care of these complex patients. Southwest Medical Associates Cardiology instituted a HF clinic in 2015, a collaboration of cardiologists with expertise in Advanced Heart Failure/Transplant, nurse practitioners, and nurse case managers. Each team member sees patients for routine medication uptitrations and as needed for hospital follow-ups. The team provides patients with extensive education regarding disease management, reinforces compliance, and closely monitors clinical status.HypothesisThe authors sought to determine the impact of a dedicated HF clinic on hospitalization rates, hospitalization costs, and left ventricular ejection fraction (LVEF). The authors wanted to determine if goals of guideline directed medical therapy (GDMT) optimization were met.MethodsData was collected on a cohort of 412 HFrEF patients who have been enrolled in the program for at least six months since 2016. Comparisons were made between six months before enrollment and six months after.ResultsHospitalization rates dropped from 0.61% to 0.29% (p=<.00001). Hospitalization costs decreased from $1035 to $828 (p=0.177). Average LVEF increased from 28% to 37% (p=.00001).Average lisinopril and losartan doses were unchanged. Lisinopril usage increased from 24.9% to 35.6% (p=.00084). Losartan usage increased from 6.1% to 19.2% (p=<.00001). Average carvedilol dose increased from 13 mg to 17 mg BID (p=0.001362). Metoprolol succinate dose increased from 50 mg to 108 mg daily. (p=0.000118). Carvedilol use increased from 11% to 46.2% (p=<.00001). Metoprolol use increased from 3.4% to 20.6% (p=< .00001). Spironolactone use increased from 15.7% to 29.2% (p=0.01208).ConclusionsHaving a dedicated HF clinic led to significant reductions in HF hospitalizations and cost and a modest increase in average LVEF in 412 patients after six months. Usage of ACEis, ARBS, BBs, and spironolactone showed statistically significant increases after enrollment. Future studies may be undertaken to determine the impact of extending the clinic enrollment for more than 6 months with emphasis on hospitalization rates, changes in BNP, LVEF improvement, and cost, as well as increased dosing/utilization of GDMT. Heart failure with reduced ejection fraction (HFrEF) is one of the most costly conditions with high morbidity and mortality. There is still paucity of data for cost-effective outpatient heart failure (HF) management. In an effort to prevent hospital admissions and morbidity, the focus has shifted toward effective outpatient care of these complex patients. Southwest Medical Associates Cardiology instituted a HF clinic in 2015, a collaboration of cardiologists with expertise in Advanced Heart Failure/Transplant, nurse practitioners, and nurse case managers. Each team member sees patients for routine medication uptitrations and as needed for hospital follow-ups. The team provides patients with extensive education regarding disease management, reinforces compliance, and closely monitors clinical status. The authors sought to determine the impact of a dedicated HF clinic on hospitalization rates, hospitalization costs, and left ventricular ejection fraction (LVEF). The authors wanted to determine if goals of guideline directed medical therapy (GDMT) optimization were met. Data was collected on a cohort of 412 HFrEF patients who have been enrolled in the program for at least six months since 2016. Comparisons were made between six months before enrollment and six months after. Hospitalization rates dropped from 0.61% to 0.29% (p=<.00001). Hospitalization costs decreased from $1035 to $828 (p=0.177). Average LVEF increased from 28% to 37% (p=.00001). Average lisinopril and losartan doses were unchanged. Lisinopril usage increased from 24.9% to 35.6% (p=.00084). Losartan usage increased from 6.1% to 19.2% (p=<.00001). Average carvedilol dose increased from 13 mg to 17 mg BID (p=0.001362). Metoprolol succinate dose increased from 50 mg to 108 mg daily. (p=0.000118). Carvedilol use increased from 11% to 46.2% (p=<.00001). Metoprolol use increased from 3.4% to 20.6% (p=< .00001). Spironolactone use increased from 15.7% to 29.2% (p=0.01208). Having a dedicated HF clinic led to significant reductions in HF hospitalizations and cost and a modest increase in average LVEF in 412 patients after six months. Usage of ACEis, ARBS, BBs, and spironolactone showed statistically significant increases after enrollment. Future studies may be undertaken to determine the impact of extending the clinic enrollment for more than 6 months with emphasis on hospitalization rates, changes in BNP, LVEF improvement, and cost, as well as increased dosing/utilization of GDMT.

Beta-blocker target dosing and tolerability in a dedicated heart failure clinic in Johannesburg.

Despite the significant clinical benefits of beta-blockers in heart failure with reduced ejection fraction (HFrEF), prescription for and adherence to these agents is reported to be poor. There are few data on the use and tolerance of beta-blocker therapy in patients with HFrEF in South Africa and it is unknown whether these patients would benefit from further heart rate-lowering therapy. Data from all patients with HFrEF attending the heart failure clinic of Charlotte Maxeke Johannesburg Academic Hospital from January 2000 to December 2014 were retrospectively collected. We first determined the rates of beta-blocker intolerance in this population and then categorised the patients according to their most recent dose of beta-blocker (low, moderate or target dose) in order to identify factors associated with beta-blocker intolerance. Lastly, we used the data to identify patients who would be suitable for further treatment with heart rate-lowering therapy. Five hundred patients, with a median follow up of 58.7 months, were identified during the study period. Black South Africans constituted the majority (66.4%) and most patients had HFrEF due to hypertension (32.8%). At the last recorded clinic visit at the end of the study period, 489 patients (97.8%) were taking a beta-blocker with 59.8% prescribed a beta-blocker at target dose. Consistent with previous data, bradycardia was the commonest cause for failing to reach target beta-blocker dose. Only 61 (12%) patients were on no (n = 11) or low (n = 50) dose of beta-blocker at final clinic visit. As per current guidelines, only 10.6% (n = 53) of this cohort of patients would qualify for further treatment with heart rate-lowering therapy. In a dedicated heart failure clinic in South Africa, beta-blockers were well-tolerated in the treatment of HFrEF. The potential role of specific heart rate-lowering therapy in patients treated adequately with heart failure medication and proper up-titration of beta-blockers is relatively small.

Abstract 286: The Heart Failure Clinic: Empowering the Armor Against 30-day All-cause Readmissions

Introduction: Heart failure related recurrent hospitalizations are widely recognized as a source of burden to both patients and the health system. Hospital discharges represent a transition of care from a controlled environment to one of lesser physician oversight and can often become a catalyst for readmission. One strategy in reducing this burden is the implementation of dedicated heart failure clinics by providing ease of transition whilst ensuring disease specific care. Methods: A retrospective review of all patients discharged from the Kings County Hospital Center from October 1 st 2017 to June 30 th 2018 with a discharge diagnosis of heart failure was conducted. Patients following in the Heart Clinic (HC) were compared to those who opted for their standard follow up (SF). The option of following in the HC (intervention group) was made at the time of discharge. All included cases were followed for 30 days after discharge to determine whether an all-cause readmission occurred at any New York City Health and Hospitals affiliated hospital. Demographic data was extracted via chart review and analyzed by descriptive statistics. A Kaplan-Meier survival analysis was done to compare the time-to-event between both study cohorts. Results: There were 258 patient discharges after exclusion-criteria were applied. Overall, a sicker population was present in the HC cohort evidenced by greater NYHA Class 3 and 4 symptomatology (54.1% vs 30.4%, p=0.007) and more patients with an ejection fraction &lt;30% (58.2% vs 36.8%, p=0.014). A Kaplan Meier analysis was conducted for the 9 months of follow up. Readmission within 30 days of discharge occurred in 5 (5.4%) of the 93 patients in the intervention group, compared with 27 (16.4%) of the 165 patients without intervention. The Heart clinic group had a better event free survival with a 67.1% reduction in readmission (log rank p=0.009). The mean time to readmission in the HC cohort was lower at 27.1 days compared to 29.5 days in the SF cohort (p=0.002). Conclusion: Our study revealed a 67.1% reduction in 30-day all-cause readmission following the initiation of the clinic. There is noticeable clinical interpretation of this outcome since the heart clinic patients were a sicker cardiac population at a safety net hospital that has a large volume of uninsured, low socioeconomic status patients. The compounded biological, social and environmental factors make the case load highly prone to CHF readmissions and underscores the need for a clinically useful strategy in fighting the high morbidity, mortality and economic burden of chronic heart failure. The presented study has wide implications in promoting high quality care, reducing readmission penalties, and minimizing the cost associated with inpatient admission, especially in centers where tight financial operating margins can be a barrier to allocation of resources.

Comparison of 18-Month Outcomes of Ambulatory Patients With Reduced (≤40%) Left Ventricular Ejection Fraction Treated in a Community-Based, Dedicated Heart Failure Clinic Versus Treated Elsewhere

We sought to examine the management and outcomes of ambulatory patients with heart failure and reduced ejection fraction in a community-based, dedicated clinic. Patients with left ventricular ejection fraction (LVEF) ≤40% were actively solicited to attend a community-based, dedicated clinic. Eligible patients who chose to decline constituted our control group. Of 552 patients with LVEF ≤40% (median age 73 years and median LVEF 35%), 304 (55%) agreed to attend the clinic. Patients with worse New York Heart Association class were more likely to attend the clinic (odds ratio 2.07 [1.45, 2.95], p <0.001), whereas women were more likely to decline (odds ratio 0.63 [0.42, 0.93], p <0.022). During 18 months of follow-up, patients in the dedicated clinic significantly improved their functional capacity (56% New York Heart Association 3 to 4 at baseline vs 27% at follow-up, p <0.001) and LVEF (35% [interquartile range 25, 35] at baseline vs 35% (interquartile range 30, 40) at follow-up, p <0.001). In comparison with patients managed routinely, patients treated in a dedicated clinic achieved better guideline-recommended pharmacological treatment (65% vs 85% receiving β blockers, p <0.001, 65% vs 82% receiving renin-angiotensin inhibitors, p = 0.0006, 31% vs 45% receiving mineralocorticoid receptor antagonists, p <0.001). During follow-up, electrical device implantation was similar (6% vs 7% of dedicated-HF-clinic patients, p = 0.700). Furthermore, overall survival was better in patients treated in the clinic (log rank p = 0.0006), even after censoring the first 4 months to account for potential bias (log rank p = 0.0232). In conclusion, management in a community-based, dedicated clinic compared with routine management was associated with augmented guideline-recommended treatment and improved survival.

Use of ReDS Technology to Treat Heart Failure in the Home Health Setting

Background Volume overload is a major determinant in the physical symptoms and quality of life in patients with heart failure (HF), as well as the predominant factor leading to HF admissions. Accurate assessment of a patient's volume status can be difficult. The Remote Dielectric Sensing (ReDS) Wearable System is an FDA-approved device developed by Sensible Medical Innovations that allows a health care provider to accurately, quickly and non-invasively measure lung fluid. In this study, we used the ReDS system to facilitate a nurse-led care transitions program to improve outcomes and reduce HF readmission rate in a rural hospital lacking an onsite HF program. Methods Randolph Hospital (RH) is a non-profit facility in central North Carolina with a 30-day HF readmission rate ≥ 25%. Medicare patients admitted for HF were enrolled into a nurse-led care transitions program. Patients received telephone follow up or home visit by a nurse within 3 days of discharge. Patients were instructed to call the care transitions nurse with any signs or symptoms of worsening HF during the follow-up period. If the patient complained of volume overload or increased dyspnea a nurse would travel to the patient's home to assess the patient and obtain a ReDS measurement. If the ReDS reading was consistent with volume overload (lung fluid > 35%), a specifically-designed diuretic protocol was initiated. Daily ReDS readings were performed and treatment protocol followed until the reading was below 35% or the protocol was stopped by the medical director. Renal function and electrolytes were monitored and replaced following pre-specified protocol. Results The Care Transitions Team has evaluated 61 patients thus far. There have been 32 elevated readings (ReDS > 35%) which triggered implementation of treatment using the diuretic-protocol. It took an average of 2.5 visits to titrate diuretics and obtain a reading Conclusions A nurse-led care transitions program employing ReDS technology and a specifically-designed diuretic protocol to manage HF patients post hospital discharge, was successful in reducing 30-day HF readmission and reduce overall resource utilization in a community hospital without a dedicated HF clinic.

P3749Management in a dedicated heart failure clinic is associated with improved over-all survival

P3749Management in a dedicated heart failure clinic is associated with improved over-all survival

Angiotensin Receptor Neprilysin Inhibitor Therapy Improves Ejection Fraction in Patients with Systolic Heart Failure

Introduction The PARADIGM-HF study showed that angiotensin receptor-neprilysin inhibitor (ARNI) therapy with sacubitril/valsartan significantly reduced cardiovascular mortality, heart failure hospitalization, and all-cause mortality compared to ace inhibitor therapy with enalapril in patients with heart failure with reduced ejection fraction (HFrEF). Since being fast tracked for HFrEF treatment in 2015, ARNI has been studied in various aspects related to efficacy and long-term effects. However, the effect of ARNI specifically on ejection fraction (EF) in patients with HFrEF on guideline directed medical therapy (GDMT) remains unknown. Hypothesis Given preliminary data, our hypothesis is that patients with heart failure on GDMT will show significant recovery and improvement in EF after initiating ARNI therapy. Methods A retrospective chart review was conducted to identify all patients treated with ARNI at a dedicated heart failure clinic in the past 12 months meeting the following criteria: (i) age ≥ 18 years, (ii) NYHA class II-III symptoms, (iii) on GDMT (beta blocker, ace inhibitor/angiotensin receptor blocker, and aldosterone antagonist) prior to ARNI initiation, (iv) EF ≤35% at time of ARNI initiation, (v) HFrEF on echo for ≥6 months prior to ARNI initiation, and (vi) follow up echo >3-6 months after ARNI initiation. Interval changes in EF since starting ARNI were compared changes in EF prior to starting ARNI. Results Patients started on ARNI showed significant recovery and improvement in EF at an average follow up of 6 months compared to EF at time of ARNI initiation (32.7% vs 22.6%, respectively, p = 0.0013). Conclusions ARNI therapy shows significant improvement and recovery of EF in patients with HFrEF on GDMT. These findings suggest that ARNI therapy could potentially reduce or delay the necessity for defibrillators and other costly procedures, while also contributing to decreased rates of hospitalizations and overall morbidity and mortality of patients with systolic heart failure.

PS206 The Impact of a Dedicated Heart Failure Clinic in Guyana on Cardiovascular Outcomes

PS206 The Impact of a Dedicated Heart Failure Clinic in Guyana on Cardiovascular Outcomes

Remote monitoring in heart failure.

In the developed world, there has been a substantial increase over several decades in the prevalence of congestive heart failure (CHF), partly as a result of demographic changes. Overall, 1–2% of the adult population has CHF and this increases to ≥10% in the over 70s age group.1 However, hospitalization rates due to CHF are falling,2 and length of hospital stay and in-hospital mortality have also fallen.3 It could be argued that effective outpatient management of CHF through dedicated heart failure clinics, specialist nurses, and general practitioners has played a key role in these positive trends. However, given the significant patient morbidity and the inpatient costs associated with CHF, methods to reduce hospital readmission rates are imperative to alleviate an already overstretched system. Rahimi and colleagues4 present the development and assessment of an easy-to-use, android-based monitoring system to empower patients and reduce readmission rates in a cohort from the Seamless User-centred Proactive Provision Of Risk-stratified Treatment for Heart Failure (SUPPORT-HF) study. Patients were provided with internet-enabled tablets that were connected to commercially available sensors to record blood pressure, heart rate, and weight, and provide alerts to patients to see their doctor or healthcare provider when physiological parameters were perturbed. Although this particular self-management study focused primarily on patient uptake of monitoring … [↵][1]*Corresponding author. Tel: +44 1603 592376, Fax: +44 1603 593752, Email: m.frenneaux{at}uea.ac.uk [1]: #xref-corresp-1-1

Rationale, Design, Methodology and Hospital Characteristics of the First Gulf Acute Heart Failure Registry (Gulf CARE).

Background:There is paucity of data on heart failure (HF) in the Gulf Middle East. The present paper describes the rationale, design, methodology and hospital characteristics of the first Gulf acute heart failure registry (Gulf CARE).Materials and Methods:Gulf CARE is a prospective, multicenter, multinational registry of patients >18 year of age admitted with diagnosis of acute HF (AHF). The data collected included demographics, clinical characteristics, etiology, precipitating factors, management and outcomes of patients admitted with AHF. In addition, data about hospital readmission rates, procedures and mortality at 3 months and 1-year follow-up were recorded. Hospital characteristics and care provider details were collected. Data were entered in a dedicated website using an electronic case record form.Results:A total of 5005 consecutive patients were enrolled from February 14, 2012 to November 13, 2012. Forty-seven hospitals in 7 Gulf States (Oman, Saudi Arabia, Yemen, Kuwait, United Gulf Emirates, Qatar and Bahrain) participated in the project. The majority of hospitals were community hospitals (46%; 22/47) followed by non-University teaching (32%; 15/47 and University hospitals (17%). Most of the hospitals had intensive or coronary care unit facilities (93%; 44/47) with 59% (28/47) having catheterization laboratory facilities. However, only 29% (14/47) had a dedicated HF clinic facility. Most patients (71%) were cared for by a cardiologist.Conclusions:Gulf CARE is the first prospective registry of AHF in the Middle East, intending to provide a unique insight into the demographics, etiology, management and outcomes of AHF in the Middle East. HF management in the Middle East is predominantly provided by cardiologists. The data obtained from this registry will help the local clinicians to identify the deficiencies in HF management as well as provide a platform to implement evidence based preventive and treatment strategies to reduce the burden of HF in this region.

Abstract 291: Impact of an Outpatient Cardiology Heart Failure Discharge Clinic on 30-day Readmission Rates for Patients with a Recent Admission for Heart Failure.

Introduction: Heart failure (HF) is a frequent cause of hospitalization in the USA with readmission rates as high as 25%. Given the focus on healthcare costs, healthcare systems are investigating ways to lower readmission rates. Dedicated HF clinics have been shown to improve mortality and decrease hospitalizations. This study was designed to evaluate the impact of a HF clinic staffed by cardiology fellows at an urban institution with an ethnically diverse and economically disadvantaged patient population on institutional readmission rates for heart failure. Methods: Using a system wide discharge database and electronic health record (EHR), patients admitted with a primary diagnosis of HF were identified between January 1 st 2011 and March 2012. Using the EHR, patients who were followed up after their hospitalization in our HF discharge clinic were identified. In clinic, patients’ weights and volume status were clinically assessed, medications were optimized, HF education was reinforced to patients and caretakers and further outpatient follow up was arranged. The study group was comprised of those who were readmitted within 30 days for any cause and had been followed in the clinic. The 30-day all cause readmission rates following a HF hospitalization in the year prior to the initiation of the HF clinic and in the year after its creation were compared. Results: From January 2011 through March 2012, 154 patients were admitted with the diagnosis of HF; 61 of the 154 (39.6%) hospitalized were seen in the HF clinic following their hospitalization, with an average appointment time of 9.5 days after discharge; 23 of the 154 patients (14.9%) were readmitted within 30 days of their index HF hospitalization. Of the 23 patients readmitted, 4 were seen in the HF clinic following their index HF hospitalization; the average time to follow up in clinic of these 4 patients was 5 days. Accordingly, the 30-day readmission rate for patients seen in the HF clinic was 6.5% versus 20.4% for those not evaluated in the clinic (p = 0.018). In the year preceding the creation of the HF discharge clinic, the 30-day hospital readmission rate for an index HF admission was 20.6%, which decreased to 14.1% in the year after the founding of the clinic (p= 0.01). Conclusion: A HF clinic operated by Cardiology Fellows at an urban medical center with a diverse patient population where patients were seen in follow up shortly after a HF hospital discharge was associated with a 13.9% reduction in 30-day all cause rehospitalization. This study suggests that a dedicated heart failure clinic may be a factor in reducing heart failure readmissions.

Ruhepuls und funktionelle Einschränkungen als prognostische Parameter bei herzinsuffizienten Patienten im tatsächlichen Leben. Daten aus dem Herzinsuffizienz-Register der ÖKG

Elevated heart rate (70 beats per minute-bpm or more) is a predictor of impaired prognosis in patients with ischemic heart failure. The Austrian Working Group on Heart Failure has established a registry in May 2006 for all patients referred to dedicated heart failure clinics with a planned follow-up after 12 ± 3 months. Here we report an analysis of the prognostic impact of elevated heart rate at referral in a well-defined cohort of heart failure patients. Between May 2006 and October 2009 1904 patients have been documented in the Austrian Heart Failure Registry. One thousand threehundred and sixty three patients (72%) had sinus rhythm at referral. Kaplan-Meier and Cox proportional hazards regression analyses were used to compare overall and cardiovascular mortality between high (70 bpm or more) and low heart-rate groups. Patients who were lost-to-follow-up (n = 166) were censored at the time of last contact. At baseline in 793 patients (58%) heart rate has been elevated (70 bpm or more) while in 562 patients it has been below 70 bpm, in 8 patients no baseline heart rate has been recorded. Groups were equally balanced regarding age, gender and cardiovascular risk factors with the exception of smokers (more active smokers in the high heart-rate group: 23 vs 14%; p = 0.001) and valvular cause of heart failure (more frequent in the high heart-rate group: 3% vs 1%; p = 0.012). Patients in the high heart-rate group had significantly higher median NT-pro-BNP (1470 pg/ml, IQR 499-4188 pg/ml) compared to patients in the low heart-rate group (784 pg/ml, IQR 314-2162 pg/ml; p < 0.001). NYHA functional classes III and IV have been more frequent in the high heart-rate group than in the low heart-rate group (32% and 22%, respectively; p < 0.001) while reduced left ventricular ejection fraction (39% or less) has been more frequent in the high heart-rate group than in the low heart-rate group (71% and 61%, respectively; p < 0.001). In the high heart-rate group treatment with beta-blockers has been less frequent than in the low heart rate group (76% and 86%, respectively; p < 0.01) while dosage of beta-blocker therapy has been comparable in both groups. Of the 75 patients who died within 3.5 years 38 deaths had a cardiovascular cause. Cox proportional hazards analysis revealed that high NYHA functional class (III and IV) and elevated heart rate (70 bpm or more) were the best predictors of overall mortality while cardiovascular mortality could best be predicted by NYHA functional classes III and IV. Higher NYHA-functional classes and elevated heart rate are predictors of adverse outcome in chronic heart failure patients.

256 A dedicated heart failure clinic improves patient management and reduces readmissions

Background and objectives Readmissions of patients with congestive heart failure (CHF) are very common because of inappropriate patient management or follow-up. Several short-term randomised studies have demonstrated the value of management of these patients within a heart failure clinic but no long-term evidence is available. Our objective was to investigate the impact of the creation of a dedicated heart failure clinic within a general hospital on patient readmissions. Programme We set up a heart failure clinic at Pontoise General hospital in January 2002 for the management of in- and out-patients. It comprises an acute care unit, a day-hospital, and a therapeutic patient education unit. Management in the clinic is offered to all patients with CHF, regardless of age, who are discharged from hospital, in liaison with out-of-hospital cardiologists and general practitioners. We analysed the impact of the creation of the heart failure unit on hospital readmissions. Results From 2000 to 2006, there were 3702 hospital admissions for CHF. Mean patient age was 72.3±5 years. Mean left ventricular ejection fraction (LVEF) was 36± 5%. Most patients were suffering from multiple diseases. During the period 2000 to 2006, the length of the initial hospital stay decreased significantly (−26%, p Conclusion In real life, management of CHF patients in a dedicated heart failure clinic markedly reduces the rate of readmissions and thus heart failure related hospital costs. L9insuffisance cardiaque est une pathologie marquee par un tres fort taux de rehospitalisation en partie lie a une prise en charge inadaptee du patient ou a des erreurs de suivi. Plusieurs etudes ont demontre l9impact d9une prise en charge specifique de ces patients mais aucune ne s9est interessee a l9impact a long terme de la creation d9une telle structure. Nous avons cree une unite therapeutique d9insuffisance cardiaque au centre hospitalier de Pontoise en 2002. Celle-ci comprend une unite de prise en charge aigue, une unite therapeutique d9hopital de jour et une unite d9education therapeutique. Celle-ci a pour vocation de prendre en charge tous les patients insuffisants cardiaques systoliques quelque soit leur âge. Une telle prise en charge etait systematiquement proposee aux patients en lien avec les cardiologues et medecins de ville a leur sortie. Nous avons analyse toutes les hospitalisations pour insuffisance cardiaque entre 2000 et 2006 (3072 hospitalisations). L9âge moyen de nos patients etait de 72.3±5, la fraction d9ejection moyenne etait de 36±5%, la plupart des patients etaient poly-pathologiques. Entre 2000 et 2006, la duree de sejour diminue significativement (−26% p Conclusion la mise en œuvre d9unites therapeutiques d9insuffisance cardiaque permet une amelioration de la prise en charge des patients et une meilleure efficience en diminuant les couts de prise en charge et en diminuant les rehospitalisations.

Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: Findings from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF)

National guidelines recommend heart failure (HF) disease management programs to facilitate adherence to evidence-based practices. This study examined the influence of dedicated HF clinics on delivery of guideline-recommended therapies for cardiology practice outpatients with HF and reduced left ventricular ejection fraction. IMPROVE HF, a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic systolic HF. Adherence to guideline-recommended HF therapies was recorded, and the presence of a dedicated HF clinic was assessed by survey. Multivariate models identified contributions to delivery of guideline-recommended HF therapies. Of practices, 41.3% had a dedicated HF clinic. Practices with a dedicated HF clinic had greater adherence to 3 of 7 guideline-recommended HF therapy measures: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (P = .02), beta-blocker (P = .025), and HF education (P = .009). After adjustment, use of a dedicated HF clinic was associated with greater conformity in 2 of 7 measures: cardiac resynchronization therapy (P = .036) and HF education (P = .005) but not angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aldosterone antagonist, implantable cardioverter-defibrillator therapy, and anticoagulation for atrial fibrillation. Use of dedicated HF clinics varied in cardiology outpatient practices and was associated with greater use of cardiac resynchronization therapy and HF education but not other guideline-recommended therapies.

Evidence of clinical practice heterogeneity in the use of implantable cardioverter-defibrillators in heart failure and post–myocardial infarction left ventricular dysfunction: Findings from IMPROVE HF

Clinical guidelines recommend implantable cardioverter-defibrillators (ICDs) for selected patients with chronic left ventricular dysfunction (LVD) to improve survival, yet ICD treatment rates for eligible patients with LVD or heart failure (HF) in cardiology practices remain poorly studied. This study sought to determine patient and practice characteristics associated with ICD use in the outpatient setting. IMPROVE HF (Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting), a prospective cohort study, is designed to characterize management of HF with reduced left ventricular ejection fraction (LVEF < or =35%). Baseline data were collected for 15,381 patients attending 167 outpatient cardiology practices located in the U.S. By current guidelines, 7,221 patients met eligibility for ICD implantation (+/- cardiac resynchronization therapy [CRT]), of whom 3,659 (50.7%) received either ICD (63.8%) or CRT with defibrillator (36.2%). Individual practice conformity for guideline-recommended ICD use ranged from 0% to 100% (27.3% to 74.6% at the 10th and 90th percentiles, respectively). Adjusted analyses revealed lack of adherence for ICD use most notably with advancing age (odds ratio: 0.87; 95% confidence interval: 0.82 to 0.93 per 10 years), black race (odds ratio: 0.75; 95% confidence interval: 0.60 to 0.94), and lack of insurance (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78). Characteristics of increased adherence included male sex, ischemic disease, atrial fibrillation, and wider QRS. Practices in the Northeast U.S. were more likely to adhere to guidelines (P <.001), as were those with a dedicated HF clinic (P = .004) and electrophysiologists on staff (P <.001). Although a number of patient and practice characteristics are associated with guideline-based ICD use, there is significant unexplained variation in the use of ICD therapy for sudden death prophylaxis across cardiology practices.

Influence of Advance Practice Nurse and Dedicated Heart Failure Clinics on Delivery of Recommended Therapies in Outpatient Cardiology Practices: IMPROVE HF Findings

Influence of Advance Practice Nurse and Dedicated Heart Failure Clinics on Delivery of Recommended Therapies in Outpatient Cardiology Practices: IMPROVE HF Findings