Evidence-based Heart Failure Research Articles

Multimorbidity patterns in adults admitted to hospital with heart failure: an analysis of 175 million hospitalisation episodes

Abstract Background The prevalence of heart failure (HF) is increasing as a result of population ageing, improved survival following myocardial infarction and the widespread uptake of evidence-based HF treatments. Greater understanding of multimorbidity patterns in patients with HF may enable the development of treatment strategies that target multiple, related long-term conditions (LTCs), producing synergistic benefits. Purpose To characterise multimorbidity patterns in patients with HF and compare these to a matched population without HF. Methods A retrospective matched cohort study was conducted using the United States National Readmission Database (NRD), 2010–2020. International Classification of Disease (ICD) codes were used to identify HF and 92 other common LTCs. The most frequent combinations of LTCs were identified for individuals with HF and a control cohort of individuals of the same age and sex, with a non-HF-related hospital admission in the same year (matched in a 1:5 ratio). Multivariable regression analysis (adjusted for age, sex, socioeconomic status, tobacco use, year of hospitalisation, and hospital characteristics) was used to evaluate the association between multimorbidity burden, length of stay (LOS; negative binomial regression) and 30-day readmission (logistic regression). Results From a total of 175,388,410 hospitalisation episodes, 3,913,924 individuals with an HF-related hospitalisation were identified and matched to 19,552,954 controls (Figure 1a). The median (interquartile range, IQR) age of a patient admitted with HF was 74 (63–85) years; 1,856,268 (47.5%) were female. The most common comorbidities in those with HF were hypertension (87.2 vs. 72.8% in matched controls), chronic kidney disease (CKD; 55.3 vs. 34.6%), coronary artery disease (CAD; 53.7 vs. 31.0%), dyslipidaemia (46.9 vs. 39.7%), diabetes (46.6 vs. 33.9%), atrial fibrillation (AF; 43.0 vs. 23.0%) and anaemia (33.2 vs. 30.1%; p all < 0.001). Patients with HF had a greater number of LTCs compared with matched controls (median [IQR] 7 [5–9] vs. 6 [4–8]; p < 0.001). From 2010–2020, the number of LTCs in those with an HF admission increased (from 6 [4–8] in 2020, to 8 [6–10] in 2020; Figure 1b). The most common multimorbidity patterns in those with HF are presented in Figure 2. In the HF cohort, a greater multimorbidity burden was associated with a longer LOS (+6% for each additional LTC; 95% confidence interval [CI] 5–7%; p<0.001) and greater risk of 30-day readmission (adjusted odds ratio [aOR] for 6 vs. 0 LTCs: 1.15, 95% CI 1.08–1.22; aOR for ≥12 vs. 0 LTCs: 1.54, 95% CI 1.45–1.64). Conclusions Patients admitted to hospital with HF have a significant burden of multimorbidity, which has increased over time and is associated with increased length of stay and unplanned hospital re-admission. The high prevalence of multiple LTCs warrants the development of novel treatment strategies that target common multimorbidity patterns observed in HF.

Evaluation and Management of Chronic Heart Failure in Children and Adolescents With Congenital Heart Disease: A Scientific Statement From the American Heart Association.

With continued medical and surgical advancements, most children and adolescents with congenital heart disease are expected to survive to adulthood. Chronic heart failure is increasingly being recognized as a major contributor to ongoing morbidity and mortality in this population as it ages, and treatment strategies to prevent and treat heart failure in the pediatric population are needed. In addition to primary myocardial dysfunction, anatomical and pathophysiological abnormalities specific to various congenital heart disease lesions contribute to the development of heart failure and affect potential strategies commonly used to treat adult patients with heart failure. This scientific statement highlights the significant knowledge gaps in understanding the epidemiology, pathophysiology, staging, and outcomes of chronic heart failure in children and adolescents with congenital heart disease not amenable to catheter-based or surgical interventions. Efforts to harmonize the definitions, staging, follow-up, and approach to heart failure in children with congenital heart disease are critical to enable the conduct of rigorous scientific studies to advance our understanding of the actual burden of heart failure in this population and to allow the development of evidence-based heart failure therapies that can improve outcomes for this high-risk cohort.

Enhancing implementation of evidence-based heart failure therapies in clinical practice: vital to modern medicine

Enhancing implementation of evidence-based heart failure therapies in clinical practice: vital to modern medicine

Association of a Heart Failure Management Incentive in Primary Care With Clinical Outcomes: A Retrospective Cohort Study.

We aim to examine the association between primary care physicians' billing of Q050A, a pay-for-performance heart failure (HF) management incentive fee code, and the composite outcome of mortality, hospitalization, and emergency department visits. This population-based cohort study linked administrative health databases in Ontario, Canada, for patients with HF aged >66 years between January 1, 2008, and March 31, 2020. Cases were patients with HF who had a Q050A fee code billed. Cases and controls were matched 1:1 on age, sex, patient status on being rostered to a primary care physician, cardiologist, or internist visit in the 6 months before study enrollment, Johns Hopkins Adjusted Clinical Group resource use bands, days between HF diagnosis and study enrollment (±2 years), and the logit of the propensity score. A Cox proportional hazards model assessed the association of Q050A with the outcome. A total of 59 664 cases had a Q050A billed, whereas 244 883 patients did not. Before matching, patients who had a Q050A billed were more likely to be men (52% versus 49%), were rostered to a primary care physician (100% versus 96%), had a higher Charlson Comorbidity Index, and had higher health care costs. The mean follow-up was 481 days for cases and 530 days for controls. The composite outcome (hazard ratio, 1.11 [95% CI, 1.09-1.12]) was significantly higher for cases than controls. The Q050A incentive improved financial compensation for primary care physicians managing patients with HF but was not associated with improvements in the outcome. Research on promoting evidence-based HF management is warranted.

Optimization of Evidence-Based Heart Failure Medications After an Acute Heart Failure Admission

The Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by N-Terminal Pro-Brain Natriuretic Peptide Testing of Heart Failure Therapies (STRONG-HF) trial strived for rapid uptitration aiming to reach 100% optimal doses of guideline-directed medical therapy (GDMT) within 2 weeks after discharge from an acute heart failure (AHF) admission. To assess the association between degree of GDMT doses achieved in high-intensity care and outcomes. This was a post hoc secondary analysis of the STRONG-HF randomized clinical trial, conducted from May 2018 to September 2022. Included in the study were patients with AHF who were not treated with optimal doses of GDMT before and after discharge from an AHF admission. Data were analyzed from January to October 2023. The mean percentage of the doses of 3 classes of HF medications (renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists) relative to their optimal doses was computed. Patients were classified into 3 dose categories: low (<50%), medium (≥50% to <90%), and high (≥90%). Dose and dose group were included as a time-dependent covariate in Cox regression models, which were used to test whether outcomes differed by dose. Post hoc secondary analyses of postdischarge 180-day HF readmission or death and 90-day change in quality of life. A total of 515 patients (mean [SD] age, 62.7 [13.4] years; 311 male [60.4%]) assigned high-intensity care were included in this analysis. At 2 weeks, 39 patients (7.6%) achieved low doses, 254 patients (49.3%) achieved medium doses, and 222 patients (43.1%) achieved high doses. Patients with lower blood pressure and more congestion were less likely to be uptitrated to optimal GDMT doses at week 2. As a continuous time-dependent covariate, an increase of 10% in the average percentage optimal dose was associated with a reduction in 180-day HF readmission or all-cause death (primary end point: adjusted hazard ratio [aHR], 0.89; 95% CI, 0.81-0.98; P = .01) and a decrease in 180-day all-cause mortality (aHR, 0.84; 95% CI, 0.73-0.95; P = .007). Quality of life at 90 days, measured by the EQ-5D visual analog scale, improved more in patients treated with higher doses of GDMT (mean difference, 0.10; 95% CI, -4.88 to 5.07 and 3.13; 95% CI, -1.98 to 8.24 points in the medium- and high-dose groups relative to the low-dose group, respectively; P = .07). Adverse events to day 90 occurred less frequently in participants with HIC who were prescribed higher GDMT doses at week 2. Results of this post hoc analysis of the STRONG-HF randomized clinical trial show that, among patients randomly assigned to high-intensity care, achieving higher doses of HF GDMT 2 weeks after discharge was feasible and safe in most patients. ClinicalTrials.gov Identifier: NCT03412201.

Integrating palliative care and heart failure: a systematic realist synthesis (PalliatHeartSynthesis)

Objectives(1) Develop a programme theory of why, for whom and in what contexts integrated palliative care (PC) and heart failure (HF) services work/do not work; (2) use the programme theory...

Evidence-based heart failure therapies at discharge of patients with acute coronary syndromes and reduced ejection fraction: Data from the ACSIS survey

Abstract Background Guideline-directed medical therapies for heart failure (HF) may benefit patients with reduced left ventricular ejection fraction (LVEF) following acute coronary syndromes (ACS), even in the absence of overt HF. Few real-world data are available regarding early implementation of HF therapies in patients with ACS and reduced LVEF. Methods Data collected from the 2021 nationwide, prospective ACS Israeli Survey (ACSIS). Drug classes included: (a) angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) or angiotensin receptor-neprilysin inhibitor (ARNI); (b) beta-blockers; (c) mineralocorticoid receptor antagonist (MRA) and (d) sodium-glucose cotransporter-2 inhibitors (SGLT2I). Utilization of HF therapies at discharge or 90-days following ACS was analyzed in relation to LVEF [reduced ≤40% (n=406) or mildly-reduced 41-49% (n=255)] and short-term adverse outcomes. Results History of HF, anterior wall myocardial infarction and Killip class II-IV (32% vs. 14% p&amp;lt;0.001) were more prevalent in those with reduced compared to mildly-reduced LVEF. ACEI/ARB/ARNI and BBC were used by &amp;gt;85% of patients in both LVEF groups, though ARNI was prescribed to only 3.9% (LVEF≤40%). MRA was used by 42.9% and 12.2% of patients with LVEF ≤40% and 41-49%, respectively, and SGLT2I in a quarter of both LVEF groups. Overall, ≥3 HF drug classes were documented in 44% of the patients. A trend towards higher rates of 90-day HF rehospitalizations, recurrent ACS or all-cause death was noted in those with reduced (7.6%) vs. mildly-reduced (3.7%) LVEF, p=0.084. No association was observed between the number of HF drug classes, or the use of ARNI and/or SGLT2I with adverse clinical outcomes. Conclusions In current clinical practice, the majority of patients with reduced and mildly-reduced LVEF are treated by ACEI/ARB and beta-blockers early following ACS, whereas MRA is underutilized and the adoption of SGLT2I and ARNI is low. A greater number of therapeutic classes was not associated with reduced short-term rehospitalizations or mortality.Drug therapies for heart failure

ACCESS TO HEART FAILURE SERVICES IN CANADA: FINDINGS OF THE HEART & STROKE NATIONAL HEART FAILURE RESOURCES AND SERVICES INVENTORY.

The rising incidence of Heart Failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched a HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted between 2020-2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, services and processes across acute care hospitals and related ambulatory settings. HF-RaSIs was completed by 501 acute care hospitals and urgent care centers, representing 94.7% of all HF hospitalizations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centers with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to brain natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present in 108 sites (21.6%), and 81 sites (16.2%) had dedicated inpatient interdisciplinary HF teams. There were 141 HF clinics (28.1% of all sites); of these, 57 (40.4%) had average wait times from referral to first appointment of > 2 weeks. Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

Predictors and prognostic implications of hospital-acquired pneumonia in patients admitted for acute heart failure.

Data on predictors and prognosis of hospital acquired pneumonia (HAP) in patients admitted for acute heart failure (AHF) to intensive care units (ICU) are scarce. Better knowledge of these factors may inform management strategies. This study aimed to assess the incidence and predictors of HAP and its impact on management and outcomes in patients hospitalised for AHF in the ICU. this was a retrospective single-centre observational study. Patient-level and outcome data were collected from an anonymized registry-based dataset. Primary outcome was in-hospital all-cause mortality and secondary outcomes included length of stay (LOS), requirement for inotropic/ventilatory support, and prescription patterns of heart failure (HF) drug classes at discharge. Of 638 patients with AHF (mean age, 71.6 ± 12.7 years, 61.9% male), HAP occurred in 137 (21.5%). In multivariable analysis, HAP was predicted by de novo AHF, higher NT proB-type natriuretic peptide levels, pleural effusion on chest x-ray, mitral regurgitation, and a history of stroke, diabetes, and chronic kidney disease. Patients with HAP had a longer LOS, and a greater likelihood of requiring inotropes (adjusted odds ratio, OR, 2.31, 95% confidence interval, CI, 2.16-2.81; p < 0.001) or ventilatory support (adjusted OR 2.11, 95%CI, 1.76-2.79, p < 0.001). After adjusting for age, sex and clinical covariates, all-cause in-hospital mortality was significantly higher in patients with HAP (hazard ratio, 2.10; 95%CI, 1.71-2.84; p < 0.001). Patients recovering from HAP were less likely to receive HF medications at discharge. HAP is frequent in AHF patients in the ICU setting and more prevalent in individuals with de novo AHF, mitral regurgitation, higher burden of comorbidities, and more severe congestion. HAP confers a greater risk of complications and in-hospital mortality, and a lower likelihood of receiving evidence-based HF medications at discharge.

Guideline-Directed Medical Therapies for Heart Failure with a Reduced Ejection Fraction in Older Adults: A Narrative Review on Efficacy, Safety and Timeliness.

Heart failure is a prevalent syndrome among older adults, with a major impact on morbidity and mortality. Higher age is correlated with underuse of guideline-directed medical therapies which, in turn, has been linked to worse clinical outcomes. Importantly, most evidence so far has been collected in adults who were younger, less multi-morbid and polymedicated compared with those who are commonly treated in daily clinical practice. Hence, we aimed to assess and describe the evidence base for pharmacotherapy in older adults with heart failure with a reduced ejection. First, a narrative review was undertaken using Medline, from inception to January 2023. Four foundational therapies were selected based on the latest European Society of Cardiology clinical practice guideline: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Post hoc analyses from landmark heart failure drug trials were searched and included if they contained data on the impact of age on efficacy, safety and/or timeliness of therapies in the management of heart failure with a reduced ejection fraction. Second, a proposal was developed to support and promote the use of evidence-based heart failure pharmacotherapy in complex, older adults. In total, 11 articles were selected: 4 meta-analyses, 6 post hoc analyses and 1 review paper. No attenuation of efficacy for any of the foundational agents was found in older adults. Regarding safety, dedicated analyses showed that beta blockers, mineraloid receptor antagonists, sacubitril-valsartan, dapagliflozin and empagliflozin retained their overall benefit-risk profile regardless of age. Time to benefit was short and occurred generally within 1 month. Consensus was achieved on a five-step proposal to manage complex medication regimens in older adults suffering from heart failure. In conclusion, older adults suffering from heart failure with a reduced ejection fraction should not be denied treatment based on their age.

Nurse-Led Heart Failure Clinics: A Snapshot of Counties Manukau in 2021

Heart failure is a complex clinical syndrome associated with significant morbidity and mortality. Evidence-based heart failure therapies are essential for improving outcomes of heart failure patients and nurse-led clinics can facilitate timely initiation and up-titration of these therapies. First-time and follow-up attendances to the nurse-led heart failure clinics were recorded in a database between May and December 2021. Demographic and diagnosis information was recorded, as well as the medication titration that occurred, the limitations to up-titration, and the follow-up plan. A total of 257 first visits took place, with a cumulative total of 542 visits for these patients. Patients were seen an average of 2.1 times over this time frame; 28% of patients were NZ Māori and 34% Pacific Islander. The average age was 57.9 years. Most patients (60%) have severe left ventricular impairment. Evidence-based heart failure medications were started during 96 clinic visits, and the dose was increased in 312 clinic visits. There were 177 instances where medications were unable to be started or up-titrated, due to the COVID-19 lockdown, and the resultant telehealth mode of delivery was a particular limitation. Nurse-led heart failure clinics are essential for helping patients become established and up-titrated on evidence-based heart failure therapies in a timely manner. While the COVID-19 lockdown had a significant impact in escalating therapy for patients, the data show that significant numbers of new patients are being seen, with a large volume of up-titration activity occurring in the clinics.

Adherence and discontinuation of optimal heart failure therapies according to age

Abstract Background Guideline-recommended disease-modifying pharmacological therapies for heart failure (HF) with reduced ejection fraction are underutilized, particularly among elderly patients. Purpose We examined adherence with and discontinuation of evidence-based HF pharmacotherapy, comprising of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin-II receptor blockers (ARB), beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA), according to age. Methods Using Danish nationwide registries, we included patients with a first HF diagnosis between 2011 and 2018. Patients were stratified into three age groups, &amp;lt;65 years (reference group), 65–79 years, and ≥80 years. The average daily drug dose was calculated as median proportions of target doses one year after inclusion. Adherence was estimated by the proportion of days covered (PDC), i.e., the total number of days with the drug available for a patient alive for the whole first year of the follow-up period. Discontinuation was defined as a break of &amp;gt;90 days, and the 5-year risk of discontinuation according to age groups was estimated with the Aalen-Johansen estimator. Multivariable Cox regression models were used to evaluate the treatment discontinuation rate according to age groups. Results We included a total of 29,482 patients (&amp;lt;65 9,449 (25.4% female), 65–79 13,746 (33.1%), ≥80 6,287 (46.3%)). Advancing age was associated with lower median proportions of daily target doses (ACEi 100%, 88%, 63%; ARB 75%, 67%, 50%; BB 75%, 56%, 44%), and lower adherence (ACEi/ARB 79.1%, 77.5%, 69.4%; BB 79.1%, 78.6%, 73.8%), in the &amp;lt;65, 65–79 and ≥80 age groups respectively, one year after inclusion. Age ≥80 was associated with a higher 5-year risk of discontinuation; cumulative incidence, ACEi/ARB 41%, 44%, 51%; BB 38%, 35%, 39%, in the same age group order as above (adjusted hazard ratio: ACEi/ARB 1.60 [95% CI, 1.51–1.69]; BB 1.33 [95% CI, 1.25–1.41]). Conversely, the risk of discontinuation of MRAs differed little with age (&amp;lt;65 50%, 65–79 54%, ≥80 56%), although MRA initiation in the most elderly was less frequent (&amp;lt;65 33%, 65–79 33%, ≥80 22%). Conclusion Among a nationwide cohort of HF patients, advanced age was associated with lower proportions of daily target doses, lower adherence, and a higher rate of discontinuation of ACEi/ARB and BBs. Focus on treatment adherence and optimal dosages among elderly HF patients could improve outcomes. Funding Acknowledgement Type of funding sources: None.

Decreasing 30-Day Readmission Rates in Patients With Heart Failure.

Heart failure affects approximately 6.2 million adults in the United States and has an estimated national cost of $30.7 billion annually. Despite advances in treatment, heart failure is a leading cause of hospital readmissions. Nonadherence to treatment plans, lack of education, and lack of access to care contribute to poorer outcomes. For patients with heart failure, the mean readmission rate is 21% nationally and 23% in New York State. Before the pilot heart failure program began, the 30-day readmission rate in the study institution was 28.6%. A multidisciplinary team created a heart failure self-care pilot program that was implemented on a hospital telemetry unit with 47 patients. Patients received education on their disease process, medications, diet, exercise, and early symptom recognition. Patients received a follow-up telephone call 48 to 72 hours after discharge and were seen by a cardiologist within a week of discharge. The 30-day readmission rate for heart failure decreased by 16.6% after implementation of the pilot program, which improved patient adherence to their medication and treatment plan and resulted in a reduction of readmissions. Patients in the pilot program represented diverse backgrounds. Socioeconomic factors such as the lack of affordable, healthy food choices and easy access to resources were associated with worse outcomes. The evidence-based heart failure program improved knowledge, early symptom recognition, lifestyle modification, and adherence to medication, treatment plan, and follow-up appointments. The multidisciplinary team approach to the heart failure program reduced gaps in care and improved coordination and transition of care.

Improved 30-Day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE) Academy.

Heart failure readmissions are common, though some are preventable through evidence-based management. Despite outperforming national benchmarks for 30-day readmissions, compliance with an evidence-based institutional heart failure management pathway was inconsistent. The purpose of this project was to reduce 30-day heart failure readmission rates through an educational intervention and an electronic health record (EHR) redesign. The cardiac services nursing leadership team conducted an education and documentation needs assessment to identify knowledge gaps and practical barriers to effective utilization of evidence-based interventions for heart failure management. This intervention included an Advanced Cardiovascular Education (ACE) Academy and an EHR workflow redesign for clinical and supportive nursing staff. The 30-day heart failure readmission rates reduced immediately following the intervention, and rates continued to decrease over a 3-year follow-up. Even among hospitals outperforming national benchmarks, 30-day heart failure readmissions can be reduced and sustained with enhanced education and EHR redesign.

Grey zones in the supportive treatments of cardiac amyloidosis

Recent advances in the diagnosis and treatment of cardiac amyloidosis (CA) have translated into a longer life expectancy of patients and more challenging clinical scenarios. Compared to the past, patients with CA and heart failure (HF) currently encountered in clinical practice are a more heterogeneous population and require tailored strategies. The perception of CA as a treatable disease has opened new possibilities for the management of these patients, but many grey areas remain to be explored. The aim of this review is to provide practical suggestions for daily clinical activity in the management of challenging scenarios in CA, including the effectiveness and tolerability of evidence-based HF medication; rate vs. rhythm control in atrial fibrillation, thromboembolic risk, and anticoagulation therapies; replacement of severe aortic valve stenosis; the impact of implantable cardioverter defibrillator on survival; and the usefulness of cardiac resynchronization therapy.

The Role of AI in Characterizing the DCM Phenotype.

Dilated Cardiomyopathy is conventionally defined by left ventricular dilatation and dysfunction in the absence of coronary disease. Emerging evidence suggests many patients remain vulnerable to major adverse outcomes despite clear therapeutic success of modern evidence-based heart failure therapy. In this era of personalized medical care, the conventional assessment of left ventricular ejection fraction falls short in fully predicting evolution and risk of outcomes in this heterogenous group of heart muscle disease, as such, a more refined means of phenotyping this disease appears essential. Cardiac MRI (CMR) is well-placed in this respect, not only for its diagnostic utility, but the wealth of information captured in global and regional function assessment with the addition of unique tissue characterization across different disease states and patient cohorts. Advanced tools are needed to leverage these sensitive metrics and integrate with clinical, genetic and biochemical information for personalized, and more clinically useful characterization of the dilated cardiomyopathy phenotype. Recent advances in artificial intelligence offers the unique opportunity to impact clinical decision making through enhanced precision image-analysis tasks, multi-source extraction of relevant features and seamless integration to enhance understanding, improve diagnosis, and subsequently clinical outcomes. Focusing particularly on deep learning, a subfield of artificial intelligence, that has garnered significant interest in the imaging community, this paper reviews the main developments that could offer more robust disease characterization and risk stratification in the Dilated Cardiomyopathy phenotype. Given its promising utility in the non-invasive assessment of cardiac diseases, we firstly highlight the key applications in CMR, set to enable comprehensive quantitative measures of function beyond the standard of care assessment. Concurrently, we revisit the added value of tissue characterization techniques for risk stratification, showcasing the deep learning platforms that overcome limitations in current clinical workflows and discuss how they could be utilized to better differentiate at-risk subgroups of this phenotype. The final section of this paper is dedicated to the allied clinical applications to imaging, that incorporate artificial intelligence and have harnessed the comprehensive abundance of data from genetics and relevant clinical variables to facilitate better classification and enable enhanced risk prediction for relevant outcomes.

Abstract 11358: A Standardized Heart Failure Bundle to Provide Better Patient Care and Reduce Readmissions

In adults, heart failure (HF) is associated with increased morbidity and mortality, with projected health care costs of 70 billion by 2030. Evidence-based care identifies that early evaluation and management improves lives and is cost-effective. Streamlining strategies to facilitate care delivery can assist heart failure patients in sustaining their complex lifestyles and behavioral modifications while preventing readmissions. Utilizing a standardized heart failure bundle with evidence-based heart failure care across health systems can provide better care and reduce the 30-day readmission rate. An interdisciplinary team identified a shared need and worked together to set the patient up for success providing a seamless transition of care from inpatient to outpatient. A literature review of evidence-based heart failure care was completed. An Information Systems (IS) team was engaged in creating an HF dashboard to measure interventions and show a return of investments. A Physician Champion was brought into the team to lead the group. A nurse coordinates the initiative while ensuring all aspects are met before discharge. The bundle includes standardized patient education, pharmacy medication reconciliation (MR) before discharge, medication counseling, and HF clinic visit within 10-days of discharge.The Standardized HF bundle begins with identifying heart failure admissions utilizing a readmissions risk report. Next, ensuring medication reconciliation is completed before discharge, as well as medication counseling. A self-management tool engaged patients in care as well. Finally, ensuring the patient has a follow-up appointment within 14 days of discharge. Process metrics evaluated include scheduling and completing follow-up (F/U) appointments and completing medication reconciliation by pharmacy. Before the HF bundle, 72% of F/U appointments were scheduled, and 34.3% were completed in March 2020. MR was 55%. After the HF bundle’s implementation, 95.9% of f/U appointments were scheduled, and 69.2% were completed in March 2021. In addition, mr was 77%. The Outcomes data includes HF readmission rates. The HF readmission rates were 30.4% in early 2020. After the implementation of the HF bundle, the HF readmission rate is 18.5%.

Prescription Filling Patterns of Evidence-Based Medical Therapies for Heart Failure During the COVID-19 Pandemic in the United States

BackgroundMaintaining a steady medication supply during a public health crisis is a major health priority. We leveraged a large U.S. pharmacy-claims database to understand the use of evidence-based therapies in heart failure (HF) care during the coronavirus disease-2019 (COVID-19) pandemic.MethodsWe analyzed 27,027,650 individual claims from an all-payer pharmacy-claims database across 56,155 chain, independent and mail-order pharmacies in 14,164 zip codes in 50 states. Prescriptions dispensed (in 2-week intervals) of evidence-based HF therapies in 2020 were indexed to comparable timeframes in 2019. We normalized these year-to-year changes in HF medical therapies relative to those observed with a stable basket of drugs.ResultsFills of losartan, lisinopril, carvedilol, and metoprolol all peaked in the weeks of March 2020 and demonstrated trajectories thereafter that were relatively consistent with the reference set of drugs. Fills of spironolactone (+4%) and eplerenone (+18%) showed modest trends toward increased relative use during 2020. Fills of empagliflozin (+75%), dapagliflozin (+65%) and sacubitril/valsartan (+61%) showed striking longitudinal increases throughout 2020 that deviated substantially from year-to-year trends of the overall basket of drugs. For all 3 therapies, fills of all quantity sizes increased relatively throughout 2020. For both generic and brand-name therapies, prescription fill patterns from mail-order pharmacies increased substantially over expected trends beginning in March 2020ConclusionPrescription fills of most established generic therapies used in HF care were maintained, whereas those of sacubitril/valsartan and the sodium-glucose cotransporter-2 inhibitors steeply increased during the COVID-19 pandemic. These nationwide pharmacy claims data provide reassurance about therapeutic access, during a public health crisis, to evidence-based medications used in HF care.

P016. Evaluating the Efficacy of Focused Nurse Practitioner Visits on Heart Failure Outcomes Among Patients Enrolled in the Program for All-Inclusive Care of the Elderly (PACE): A Quality Improvement Project

Background Symptom management in heart failure (HF) is the cornerstone to improve outcomes in this complex population. Rehospitalization rates due to HF sequelae are high and symptom management remains an ongoing issue. Focused Nurse Practitioner (NP) visits with evidence-based patient education will enhance engagement and self-care management of HF. Ultimately, this will improve HF outcomes for participants in the PACE program. Purpose The purpose of this quality improvement project was to evaluate the efficacy of focused NP visits on improving HF related outcomes among participants of the PACE program in western Florida. Methods The project was based on the Information, Motivation, Behavioral skills theoretical model with patient engagement as the key mediator to achieve improved HF self-management. The NP saw each participant twice. The first visit established baseline data through questionnaires. The second visit was to discuss the evidence-based HF patient education booklet created by this author and complete the post-intervention questionnaires. Table 1 describes the outcome measures and instruments used. The outcomes evaluated included HF knowledge, quality of life, HF self-care and symptom burden, demographic data, medical history, and clinical variables. The questionnaires used included the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Atlanta HF Knowledge Test (AHFKT), the Self-Care of HF Index questionnaire (SCHFI), the Symptom Status Questionnaire - Heart Failure (SSQ-HF). Results The results for the AHFKT were statistically significant (p = .037) indicating the evidence-based education provided was effective. The self-efficacy and knowledge portion of the KCCQ was statistically significant (p = .047) indicating the education and focused NP visits increased participant knowledge and ability to effectively manage their HF. The result of the AHFKT surmises the evidence-based education provided was effective, which is supported by the results from the KCCQ on knowledge and self-efficacy. In evaluation of the symptom severity questions, it was determined that participants were more self-aware of their HF symptoms after the HF education, thus providing responses to the KCCQ that showed an inverse relationship. Conclusion The clinical implications for this practice change indicates the evidence-based education booklet is an effective tool in the management of HF when combined with focused NP visits. The NP visits showed improved outcomes and would be beneficial to HF patients ongoing. In terms of sustainability, the evidence-based education booklet has been adopted for all HF patients.

Angiotensin receptor-neprilysin inhibition in patients with acute decompensated heart failure: an expert consensus position paper.

The short-term mortality and rehospitalization rates after admission for acute heart failure (AHF) remain high, despite the high level of adherence to contemporary practice guidelines. Observational data from non-randomized studies in AHF strongly support the in-hospital administration of oral evidence-based modifying chronic heart failure (HF) medications (i.e., b-blockers, ACE inhibitors, mineralocorticoid receptor antagonists) to reduce morbidity and mortality. Interestingly, a well-designed prospective randomized multicenter study (PIONEER-HF) showed an improved clinical outcome and stress/injury biomarker profile after in-hospital administration of sacubitril/valsartan (sac/val) as compared to enalapril, in hemodynamically stable patients with AHF. However, sac/val implementation during hospitalization remains suboptimal due to the lack of an integrated individualized plan or well-defined appropriateness criteria for transition to oral therapies, an absence of specific guidelines regarding dose selection and the up-titration process, and uncertainty regarding patient eligibility.In the present expert consensus position paper, clinical practical recommendations are proposed, together with an action plan algorithm, to encourage and facilitate sac/val administration during hospitalization after an AHF episode with the aim of improving efficiencies of care and resource utilization.