Heart Failure In Community Research Articles

Influence of process-focused patient care on clinical outcomes among hospitalized heart failure patients in the cardiology ward

Abstract Background The implementation of a process-oriented organizational structure in patient care allows for a comprehensive and optimized approach. In the context of heart failure (HF), it remains uncertain whether the establishment of a specialized hospitalisation team can contribute to improved major clinical outcomes. Purpose To analyse the rates of all-cause hospitalisation, cardiovascular hospitalization, HF hospitalization and overall mortality at 180 days among patients admitted to the Cardiology ward for HF, both prior to and after the implementation of a specialized HF hospitalisation team. Methods The study included all patients discharged from the Cardiology department with HF as the primary diagnosis and subsequent outpatient follow-up by the Community HF Unit in both 2019 and 2022. Clinical outcomes were compared between two distinct periods: the pre-implementation year of 2019 and the subsequent year of 2022, characterized by process-oriented HF care. Statistical analyses were performed using Kaplan-Meier and adjusted Cox proportional-hazards models. Results A total of 140 patients were enrolled in the study, comprising 55 individuals receiving care from a conventional ward team in 2019 and 85 under the specialized HF team in 2022. The mean age of the cohort was 69.4 years (+/-11.8), with a mean LVEF of 40.6%. The pre-implementation group showed a higher percentage of male patients (73% vs. 47%; p=0.003) and LVEF was lower in the HF team period (38.9% vs. 43.4%; p=0.045), with no statistically significant differences in other baseline variables. As shown in figure 1, over 180 days of follow-up, 15 patients (27.6%) were admitted to hospital in the conventional ward team period and 13 (15.3%) in the HF team period (hazard ratio [HR] 0.44; 95% confidence interval [CI] 0.19 to 0.99; P=0.047). Of these hospitalisations, 13 patients (23.6%) in pre-implementation period and 10 (11.8%) in post-implementation period were attributed to cardiovascular events (HR 0.40; 95% CI 0.16 to 0.99; P=0.049). Additionally, there was a reduction in the rate of heart failure admissions in the post-implementation period compared to the pre-implementation time (HR 0.30; 95% CI 0.09 to 0.94; P=0.039). Furthermore, a significant decline in all-cause of death was observed in patients treated by HF-team in 2022 compared to patients receiving care from the conventional ward team (log-rank test, p=0.015). Conclusions The implementation of a process-oriented organizational model within the Cardiology unit consisting in the provision of patient care by a team specialized in HF management, is associated with a statistically significant reduction in major clinical outcomes such as all-cause hospitalization, cardiovascular hospitalization and HF readmission, alongside a reduction in overall mortality rates at 180 days.

Reducing the hospitalization epidemic of chronic heart failure by disease management programs.

Chronic heart failure is the most common cause of hospitalization in Europe and rates are steadily increasing due to aging of the population. Hospitalization identifies a fundamental change in the natural history of heart failure (HF) increasing the risk of re-hospitalization and mortality. Heart failure management programs improve the quality of care for HF patients and reduce hospitalization burden. The goals of the heart failure management programs include optimization of drug therapy, patient education, early recognition of signs of decompensation, and management of comorbidities. Randomized clinical trials evidenced that system of care for heart failure patients improved adherence to treatment and reduced unplanned re-admissions to hospital. Multidisciplinary programs and home-visiting have shown improved efficacy with reductions in HF and all-cause hospitalizations and mortality. Community HF clinics should take care of the management of stable patients in strict contact with primary care, while hospital out-patients clinics should care of patients with severe disease or persistent clinical instability, candidates to advanced treatment options. In any case a holistic, patient-centered approach is suggested, to optimize care considering the needs of the individual patient. Telemonitoring is a new opportunity for HF patients, because it allows the continuity of care at home. All heart failure patients should require follow-up in a specific management program, but most of date come from clinical trials that included high-risk patients. While clinical trials have a specified duration (from months to some years), lifelong follow-up is recommended with differentiated approaches according to the patient's need.

Regional left ventricular longitudinal strain and heart failure in a low-risk community

Abstract Background Global longitudinal strain is a well-established prognosticator of heart failure (HF) in the general population. The prognostic values of regional left ventricular (LV) longitudinal strain of the basal, mid and apical regions remain unexplored in the general population. Purpose The purpose of this study was to investigate the relationship between regional LV strain and incident HF in the general population. Methods This prospective cohort study included randomly selected citizens from a major metropolitan area. All participants were examined with echocardiography. The outcome was incident HF. Participants were excluded if regional LV strain was not assessable in all 3 LV regions or if they had atrial fibrillation or HF at baseline. A multivariable Cox regression model adjusted for sex, age, smoking status, heart rate, systolic blood pressure, history of ischemic heart disease, hypertension, diabetes, LV mass index, LV ejection fraction and E/e’ was used. Results A total of 3,952 individuals were included. Mean age was 56±18 years and 43% were male. Mean basal, mid, and apical LV strain was 16.4±2.6%, 19.5±2.6 and 22.8±3.6% respectively. Median follow-up was 5.4 years (IQR: 4.4; 6.3) and 99 developed HF. In multivariable Cox regressions models, only decreasing LV basal strain was associated with future HF (HR = 1.18, 95%CI (1.06; 1.32), P = 0.003, per 1% decrease) (Figure 1). Additionally, LV basal strain provided incremental prognostic information regarding future HF to the Atherosclerosis Risk in Communities HF risk score (continuous net reclassification index = 0.468, 95% CI (0.155; 0.687)). Conclusion In individuals from the general population, basal LV strain entailed incremental prognostic information regarding the risk of incident HF.Basal strain and incident HF

The "Triage" clinic: close communication between hospital and community heart failure unit reduces readmissions

Abstract Background Heart Failure (HF) causes an immense medical and financial burden on health systems. Recurrent hospitalizations lead to a severe reduction in quality of life and worsen prognosis. The chance of readmission is 24% within a month after discharge and over 50% within 6 months, despite great improvements in treatment. A large proportion of readmissions are for noncardiac reasons. Aim To reduce readmissions in patients recently discharged from a hospitalization for HF worsening, by improving and promoting close communication between hospital and community. Methods We initiated a pilot study at our community HF unit (HFU), whereby details of patients hospitalized for HF on two general medical wards were sent directly by the ward nursing staff to the HFU head nurse, and the patients were invited to the HFU as soon as possible after discharge (the Triage clinic). The treatment protocol included IV therapy where indicated (furosemide, iron) and titration of oral medications, with close medical and laboratory follow-up. Readmissions rates over 1, 3, 6 & 12 months (for HF or all causes, including HF) were compared to the equivalent period prior to the index admission. A further comparison was made with a control group of HF patients invited to the HFU but who chose not to attend. Results Between 2/2020 and 3/2021, 108 patients were seen in the Triage clinic, within an average time of 11 days from discharge. After the first visit, 10 patients were discharged and 1 died. 97, 75 & 46 patients completed follow-up of 3, 6 & 12 months, respectively. Readmissions for HF were 50% lower over 1,3, & 6 months compared to the equivalent period before treatment in the Triage clinic, and 15% lower after 12 months. Readmissions for all causes were 45% lower over 1, 3 & 6 months compared to the equivalent period before treatment in the Triage clinic, and 35% lower after 12 months. In the control group, 55, 33 and 15 patients completed follow-up of 3, 6 & 12 months, respectively. On comparing the Triage group to the control group, there was a reduction of 75% in recurrent admissions for HF or all causes after 1 month, and 60% reduction after 3, 6 and 12 months. In the Triage group, there were an average 2.5 changes in therapy per patient per month. On average, there was an average 1.6 IV furosemide and 2.6 IV iron treatments per patient per year. The functional capacity improved by a factor of 2.5. Conclusions Promoting close communication between hospital and community can lead to a significant improvement in HF care, as seen by better quality and efficacy of therapy and speed of access. This in turn reduces rehospitalizations and improves quality of life.

Virtual Multi-disciplinary Team (vMDT) platform improves workflows and productivity within the heart failure pathway for patients in the UK National Health Service (NHS)

Abstract Background We implemented a virtual MDT platform as a technical solution to assist a heart failure MDT. vMDT would enable the team to document discussions and create actions for individual team members that were visible and transparent and thus ensuring rapid completion relating to patient care plans. Patients cases processed via this pathway in comparison to traditional approaches were able to access treatment optimisation and newer heart failure therapies more rapidly. Data from the vMDT platform helped plan for wider transformation. Purpose Integrating care between general practice (GP), community and hospital specialists is the current focus for the National Health Service (NHS) in the UK. An integrated approach necessitated better communication and sharing of information between MDTs. We decided that it was necessary to have the digital infrastructure to deliver this approach. Method The vMDT system harnessed information relevant to the patients heart failure and presented it to MDT members to view and contribute to the patients treatment plan, before, during and after a scheduled MDT meeting. Following the meeting the platform would instantly communicate actions to members of the professional team, ensuring transparency and rapid completion of actions. Processes were simplified, meaning that patients could be referred onwards at the click of a button. The patients could be referred into this pathway by a GP when patients continued to have symptoms. Pathway was made available to GP clinics covering a 200,000 patient population. Led by the commissioning transformation team, who managed the project alongside the GP cardiovascular lead, community heart failure nurse lead, and Hospital heart failure specialist nurse leads. Clinical pharmacists linked to the GP clinics were included and were the ones who would prepare, upload and present the heart failure cases. Results 98% (150 processed over 10 months) of patients referred along this pathway could be managed effectively. 5% would otherwise have been lost to follow up. 100% of actions created through this pathway were completed. 62% had their treatment optimised. Clinician satisfaction improved. Conclusion Virtual MDTs are the rave but there needs to be digital infrastructure to support this novel way of working, especially if we are to scale this up. A digital platform needs to have the safeguards for information security but also needs to align to an improved workflow for the health professionals working within the service. In future we would like to look at whether addition of decision support can further improve productivity and outcomes relating to optimisation of therapy for heart failure patients.

Heart failure virtual consultation: caters for frailer, multimorbid and remote patients

Background: The heart failure (HF) virtual consultation (VC) is an eHealth tool for delivery of peer-to-peer specialist advice to general practitioners (GPs) to discuss HF diagnosis/management. We aim to investigate...

Community Heart Failure Service Referral Patterns in the Central Coast Local Health District (CCLHD) Throughout the COVID-19 Pandemic

Community Heart Failure Service Referral Patterns in the Central Coast Local Health District (CCLHD) Throughout the COVID-19 Pandemic

#6672 THE DEVELOPMENT OF A COMMUNITY-NEPHROLOGY, MULTI-DISCIPLINARY SERVICE

Abstract Background and Aims The Walsall Together clinical and operational leads constructed a collaborative initiative between nephrology and community services. Driven to provide multi-agency, patient-focused care. The aim of the community nephrology MDT service is to identify and optimally manage individuals with acute nephrological presentations and optimally manage individuals with secondary complications of chronic kidney disease (CKD) at home, while maximally utilising outpatient community services to prevent hospital admissions. Method Nephrology and community teams, including rapid-response, complex-case management, enhanced-care and frailty teams devised a MDT service for individuals with either community-acquired acute kidney injury (AKI) or complications of CKD. The MDT can consist of; a nephrologist, community-CKD nurse, a member from each of the above teams, a community pharmacist and an MDT coordinator. Patients are identified from the MDT attendee's caseload, from the community heart failure and the community geriatrician patient cohort. A weekly MDT meeting is held on Microsoft Teams, this allows for efficient working across a large geographical area. The MDT coordinator is essential for the efficient performance of the community nephrology MDT. They are responsible for: organising meetings, producing minutes, requesting laboratory investigations (including urine album in creatinine ratio), chasing results from clinical investigations and finally ensuring that the actions generated from the MDT are completed. The community pharmacist is an independent prescriber and immediately actions any medication changes. The community teams consist of advanced clinical practitioners or band 7/above nurse prescribers. All clinical staff perform home visits and fully utilise outpatient services including ambulatory-care-unit services for medical assessment, urgent imaging and intravenous electrolyte replacement. The medical-day-case unit services for the administration of blood transfusions. The community outpatient access team services for intravenous iron therapy and antibiotic therapy. Results Currently, the community nephrology MDT is actively managing over 60 patients. This excludes patients who have been successfully managed and discharged from the community MDT service. The multimorbid, patient cohort with recurrent hospital admissions appear to have benefited the most. A reduction and/or cessation is noted, in hospital admissions after the introduction of interventions from the community nephrology MDT. The service allows the nephrology team to easily monitor and manage housebound, individuals with CKD. This reduces the number of admissions related to secondary complications of CKD. Furthermore, by managing acute illness in the community, the service reduces the number of individuals admitted to hospital with community acquired AKI. Finally, in the unfortunate event of terminal, irreversible pathology, the MDT service allows for advanced care planning and referral to community palliative care services. Conclusion The Walsall Together collaboration has demonstrated that utilising a multi-agency approach to managing acute and chronic renal disease, can result in a reduction in hospital admissions. Furthermore, the cooperative multi-speciality approach, has led to improved monitoring and management of housebound individuals with CKD.

Translating Pressure Into Practice: Operational Characteristics of Ambulatory Hemodynamic Monitoring Program in the United States

BackgroundAmbulatory hemodynamic monitoring (AHM) using an implantable pulmonary artery pressure sensor (CardioMEMS) is effective in improving outcomes for patients with heart failure. The operations of AHM programs are crucial to clinical efficacy of AHM yet have not been described. Methods and ResultsAn anonymous, voluntary, web-based survey was developed and emailed to clinicians at AHM centers in the United States. Survey questions were related to program volume, staffing, monitoring practices, and patient selection criteria. Fifty-four respondents (40%) completed the survey. Respondents were 44% (n = 24) advanced HF cardiologists and 30% (n = 16) advanced nurse practitioners. Most respondents practice at a center that implants left ventricular assist devices (70%) or performs heart transplantation (54%). Advanced practice providers provide day-to-day monitoring and management in most programs (78%), and use of protocol-driven care is limited (28%). Perceived patient nonadherence and inadequate insurance coverage are cited as the primary barriers to AHM. ConclusionsDespite broad US Food and Drug Administration approval for patients with symptoms and at increased risk for worsening heart failure, the adoption of pulmonary artery pressure monitoring is concentrated at advanced heart failure centers, and modest numbers of patients are implanted at most centers. Understanding and addressing the barriers to referral of eligible patients and to broader adoption in community heart failure programs is needed to maximize the clinical benefits of AHM.

Community pharmacists’ perceptions on multidisciplinary heart failure care: an exploratory qualitative study

BackgroundHeart failure (HF) is an important health problem and guidelines recommend multidisciplinary management. The pharmacist is an important member of the multidisciplinary heart failure team, both in the hospital and community setting. This study aims to explore the perceptions of community pharmacists on their role in HF care.MethodsWe conducted a qualitative study based on face-to-face semi-structured interviews with 13 Belgian community pharmacists between September 2020 and December 2020. We used the Qualitative Analysis Guide of Leuven (QUAGOL) method as guidance for data analysis until data saturation was reached. We structured interview content into a thematic matrix.ResultsWe identified two major themes: heart failure management and multidisciplinary management. Pharmacists feel responsible for the pharmacological and non-pharmacological management of heart failure, citing easy access and pharmacological expertise as important assets. Diagnostic uncertainty, lack of knowledge and time, disease complexity and difficulties in communication with patients and informal care providers are barriers to optimal management. General practitioners are the most important partners in multidisciplinary community heart failure management, although pharmacists perceive a lack of appreciation and cooperation and deplore communication difficulties. They feel intrinsically motivated to provide extended pharmaceutical care in HF but cite the lack of financial viability and information sharing structures as important barriers.ConclusionThe importance of pharmacist involvement in multidisciplinary heart failure teams is undisputed by Belgian pharmacists, who cite easy access and pharmacological expertise as important assets. They point out several barriers impeding evidence-based pharmacist care for outpatients with heart failure: diagnostic uncertainty and disease complexity, lack of multidisciplinary information technology and insufficient resources. We recommend that future policy should focus on improved medical data exchanges between primary and secondary care electronic health records as well as the reinforcement of interprofessional relationships between locally affiliated pharmacists and general practitioners.

P378 HEART FAILURE DURING ACUTE CORONARY SYNDROME AND THE LONG–TERM RISK OF INCIDENT CANCER. THE ABC–9* STUDY ON HEART DISEASE

Abstract Introduction Recent reports have suggested a higher risk of incident cancer among patients with pre–existing Heart failure (HF) in community–based cohorts. Methods To investigate the association between heart failure (HF) during hospitalization with acute coronary syndrome (ACS) and the very long–term cancer risk, we enrolled 572 patients admitted with ACS to 3 Italian hospitals and discharged alive and free from neoplasia. Patients were prospectively followed for 24 years or until death. Results All except for three patients completed the follow–up, representing 6440 person–years. Patients‘ mean age was 66 ± 12 years and 70% were males. Baseline clinical HF was diagnosed in 192 (34%) patients. During follow–up, 129 patients (23%) developed cancer; of them, 103 with no HF [27% of patients without HF] and 26 had baseline HF [14% of patients with HF]. The incidence rates for cancer were 18 and 21 per 1000 person–years for patients with and without baseline HF, respectively (p = 0.62). The risks for cancer associated with HF were (HR: 0.96; 95% CI: 0.62–1.47; p=0.85). Similar associations were observed among both genders and in patients younger than 75 years of age. Yet, in patients older than 75 years, the unadjusted risk was (HR: 0.30; 95% CI: 0.09–0.92; p=0.04). However, the fully adjusted risk was (HR: 0.39; 95% CI: 0.12–1.30; p=0.13). The unadjusted HRs for incident cancer were (HR: 0.88; 95% CI: 0.45–1.74; p=0.73) and (HR: 0.91; 95% CI: 0.48–1.71; p=0.77) for patients with HFrEF and HFpEF respectively. We observed a positive interaction between age and LVEF for the risk of cancer onset (HR: 1.002; 95% CI: 1.003 –1.004; p=0.02) in the unadjusted model. Results were the same in the fully adjusted model. Conclusions A lack of association between clinical HF at admission for ACS and the long–term cancer risk has been observed in this prospective study of unselected ACS patients. A positive independent interaction between age and LVEF has been also observed.

Prevalence and incidence of heart failure among community in China during a three-year follow-up.

Epidemiological surveys on heart failure (HF) in Chinese community are relatively lacking. This study aimed to estimate the prevalence and incidence of HF among community residents in southern China. Baseline data of this prospective study was collected from 2015 to 2017 among 12,013 permanent residents aged ≥ 35 years in Guangzhou, China. The same survey process was carried out for individuals aged ≥ 65 years after a three-year follow-up. The overall prevalence of HF in community residents aged ≥ 35 years was 1.06%. Male had significantly higher risk of HF prevalence [odds ratio (OR) = 1.50, P = 0.027]. The gender-adjusted risk of HF was 1.48 times higher per 10 years aging. HF prevalence was statistically associated with atrial fibrillation, valvular heart disease, hypertension and chronic obstructive pulmonary disease after adjusting for age and gender (OR = 8.30, 5.17, 1.11, 2.28, respectively; all P < 0.05). HF incidence in individuals aged ≥ 65 years were 847 per 100,000 person-years. Baseline atrial fibrillation, valvular heart disease, and diabetes mellitus were risk factors for HF incidence for individuals aged ≥ 65 years adjusting for age and gender (OR = 5.05, 3.99, 2.11, respectively; all P < 0.05). Besides, residents with new-onset atrial fibrillation and myocardial infarction were at significantly higher risk of progression to HF (OR = 14.41, 8.54, respectively; all P < 0.05). Both pre-existing and new-onset cardiovascular diseases were associated with HF incidence in southern China. Management of related cardiovascular diseases may be helpful to reduce the incidence of HF.

Abstract P177: Circulating Ketone Bodies and Mortality in Heart Failure: A Community Cohort Study

Background: Heart failure (HF) is associated with metabolic alterations, including ketogenesis. However, determinants of ketogenesis and risk of mortality in HF is not defined. Total ketone bodies (KB) include β-hydroxybutyrate, acetoacetate, and acetone and can be measured in plasma by nuclear magnetic resonance (NMR). The aim of this study is to determine the relationship between KB and clinical characteristics in a community HF cohort and to assess the association between KB and all-cause mortality. Methods: A population-based cohort of 1,389 HF patients was prospectively enrolled between 2003 and 2012. Plasma KB was measured by LP4 NMR LipoProfile ® assay/test on the Vantera® NMR analyzer platform. A conditional inference tree method (ctree R Package) was used to determine optimal KB group cut points. Associations between clinical characteristics and KB were measured with Wilcoxon rank sum test and Pearson’s Chi-squared test. Kaplan-Meier method estimated survival. Cox regression analyses were used to estimate associations between KB concentrations and mortality. Results: Among the 1,382 HF patients with KB measurements, the median age was 78 years (IQR 68-84) and 52% were men. Median KB was 180 μM (IQR 134-308). Patients were divided into two groups with lower KB (≤471.5 μM) and higher KB (&gt;471.5 μM). Patients with higher KB (N=210) had lower BMI, higher BNP, and were more likely to be in the New York Heart Association class III-IV; however, these patients were less likely to have hyperlipidemia, coronary disease, or diabetes mellitus (P &lt; 0.05). Age, sex, creatinine, ejection fraction, or Meta-Analysis Global Group in Chronic HF (MAGGIC) score did not differ by KB group. Higher KB was associated with worse survival (figure). After adjustment for the MAGGIC score, higher KB was associated with increased risk of mortality (HR 1.3; 95% CI, 1.08-1.48). Conclusions: In this community HF cohort, higher KB was associated with increased mortality, independent of the MAGGIC score.

Abstract 10590: Detection of Cardiac Attr Amyloidosis in a Real-World Hf Population by Natural Language Processing Guided Automated Data Extraction From Electronic Health Records

Background: As cardiac aTTR amyloidosis(aTTR-CM) is frequently underdiagnosed and missed, improved screening to enhance earlier diagnosis of the disease is essential. Recent observations have demonstrated that clinical clues related to the presence of aTTR-CM and additional predisposing or associated medical conditions derived from machine learning(ML) models may provide a systematic framework to increase the suspicion of aTTR-CM in heart failure(HF) pts. Objectives: The present study was set up to explore the use of a systematic framework to diagnose aTTR-CM in a real-world HF population. Methods: Between 2014 and 2018, 3035 HF pts (Age:74 ± 12 years; EF: 45 ± 19 %, male: 50 %) consecutively referred to a community HF clinic were assessed. Using targeted disease-specific electronic health record (EHR) models (Natural language processing/ LynxCare Inc., Leuven, Be) the prevalence and odds ratios for cardiac, non-cardiac, and combinations of both cardiac and non-cardiac phenotypes predictive for aTTR-CM were assessed. Results: 101 pts((Age: 78.57 ± 9.17 years; EF 46 ±15 %, male: 40% ) were diagnosed with aTTR-CM. Besides HF and cardiomyopathy-related phenotypes, atrial fibrillation was the strongest cardiac predictor for aTTR-CM(prevalence:76 %, OR 2.95, 95% CI= 2.10, 4.14) whereas the strongest non-cardiac predictor was carpal tunnel syndrome(prevalence :21 %, OR 6.55, 95% CI= 7.21, 5.90). The combination of heart block, joint disorders, and combined systolic and diastolic HF was the highest combined phenotype in aTTR-CM(prevalence:16 %, ORR 2.63, 95% CI = 0.96, 3.28). Conclusion: On top of well-known diagnoses and phenotypes unique combinations of cardiac and non-cardiac phenotypes predict aTTR-CM In a real-world HF population. Therefore, if successfully employed in the EHR this strategy may identify aTTR-CM pts and lead to earlier detection of it by raising the suspicion of the diagnosis in HF pts.

Inferior vena cava diameter adds information to pulmonary artery systolic pressure in outpatients with heart failure

Abstract Background Evaluation of pulmonary arterial pressure (PAP) is recommended by guidelines to diagnose and monitor congestion in patients with heart failure (HF). However, the high compliance of the venous system might buffer the effects of a large increase in intravascular volume and delay an elevation in PAP. Therefore, measuring inferior vena cava (IVC) diameter by ultrasounds might add important information in patients with HF, regardless of PAP. Aim To evaluate the relationship between the IVC diameter and systolic PAP (PAsP) assessed by echocardiography with mortality in outpatients with HF. Methods We enrolled consenting out-patients attending a community HF clinic for initial diagnosis or follow-up in Kingston upon Hull, UK between 2009–2012. HF was defined as the presence of relevant symptoms and signs and objective evidence of cardiac dysfunction: either a left ventricular systolic function (LVEF) &amp;lt;50% or elevated amino-terminal pro-brain natriuretic peptide (NT-proBNP) ≥125 pg/ml. IVC was considered dilated when &amp;gt;2.0 cm, PAsP elevated when &amp;gt;35 mmHg. Results Amongst the 874 patients enrolled, median age was 75 years, 68% were men, median LVEF was 44% and median NT-proBNP was 1125 pg/ml. 468 patients (54%) had normal IVC and PAsP, 117 (13%) had normal IVC but elevated PAsP, 75 (8%) had dilated IVC but normal PAsP and 214 (25%) had both dilated IVC and elevated PAsP. Compared to those with normal IVC and PAsP, those with elevated PAsP but normal IVC were older, more likely to be women, and had higher LVEF and NT-proBNP, whilst those with dilated IVC but normal PAsP had similar age and LVEF, but more signs of congestion and higher NT-proBNP. Compared to those with both normal IVC and PAsP (reference), those with dilated IVC but normal PAsP (HR: 1.83; CI: 1.04–3.25; P=0.037) or elevated PAsP but normal IVC (HR: 1.88; CI: 1.25–2.85; P=0.003) had a similarly increased risk of death but those with a dilated IVC and elevated PAsP had the greatest risk (HR: 4.16; CI: 3.10–5.57; P&amp;lt;0.001). Conclusion A dilated IVC is associated with mortality even when PAsP is not elevated. Tailoring treatments to reduce IVC diameter is a strategy worth exploring to improve outcomes in outpatients with heart failure. Funding Acknowledgement Type of funding sources: None.

A PROPENSITY-MATCHED COHORT STUDY TO ASSESS THE EFFECTIVENESS OF A COMMUNITY HOSPITAL BASED HEART FUNCTION CLINIC

A PROPENSITY-MATCHED COHORT STUDY TO ASSESS THE EFFECTIVENESS OF A COMMUNITY HOSPITAL BASED HEART FUNCTION CLINIC

Perspective on 'Phase V' or Logistics and Regression as Logical Progression for Community Heart Failure Triage.

Congestive Heart Filur is an epidemic and its trajectory apppears to be escaling. Undoubtly tremendous gains have seen improvement in life expectancy and quality of life, however, hospital readmissions, resource utilization and health system cost continue to create challenges. In this short perspective, we raise the prospect of extending the research phases the community and real world setting. Logistic have supported service supply chains during the COVID-19 pandemic and there are lesson here to be learned.

Abstract 10515: Deep Phenotyping of Heart Failure with Machine Learning: An Echocardiographic Community Study

Introduction: Heart failure (HF) is a clinical syndrome with high mortality. Left ventricular ejection fraction (EF) determines clinical phenotyping and HF is classified most often as preserved (HFpEF) or reduced (HFrEF) EF. The importance of expanding phenotyping beyond EF is recognized. We hypothesized that machine learning applied to echocardiography will provide information important for deep phenotyping. Methods: We collected clinical and echo data in a HF community cohort between 2013 and 2017. Unsupervised clustering was applied to 23 echo variables using partitioning around medoids (PAM), with Gower dissimilarity used to address the mixed variable types. Proportional hazards regression examined the association between cluster assignment and death. Results: We identified 4978 persons with HF [mean age 73.9 years (SD 13.9), 47% women] with echocardiography within 6 months of diagnosis. We identified 2 primary clusters using echo variables, as depicted using t-Distributed Stochastic Neighbor Embedding (t-SNE) applied to the dissimilarity matrix (Figure). Diastolic function variables exhibited the largest differences by clusters as shown by absolute standardized differences (Table). After 3.2 + 1.9 years of follow up, 2001 deaths occurred. Assignment to cluster 2 was associated with a near 20% excess risk of death independent of age, sex, comorbidity, and EF [HR 1.17 (1.07, 1.28) p&lt;0.001]. Conclusions: Unsupervised clustering applied to echocardiography in a large community HF cohort identified 2 distinct clusters, which defined HF subgroups with different characteristics and were independently associated with risk of death.

NICE diagnostic heart failure pathway: screening referrals identifies patients better served by community-based management.

AimsEvaluate whether UK National Institute for Health & Care Excellence (NICE) chronic heart failure (HF) guidelines can be safely and effectively refined through specialist referral management.Methods and resultsAll referrals to a UK centre 1/3/2019–30/5/2019 and 1/6/2020–31/7/2020 were reviewed by HF specialists. Patients were triaged to specialist assessment in HF clinic, according to the NICE HF diagnostic pathway [urgency based on N‐terminal pro brain natriuretic peptide (NTproBNP) levels], or the referrer given remote Advice & Guidance (A&G), to aid primary care management. Standardized triage criteria for recommending primary care management were (i) presentation inconsistent with HF, (ii) competing comorbidity/frailty meant specialist assessment in clinic not in patient's best interests, (iii) recent assessment for same condition, or (iv) patient had known HF. Following triage patients managed in the primary care were categorized as low or high risk of adverse outcomes. Outcome measures were 90 day all‐cause and HF hospital admission and mortality rates. Four hundred and eighty‐six patients had the median age of 80 (74–86) years, and 253 (52%) were male. Two hundred and six (42%) had NTproBNP > 2000 pg/mL. Primary care management was recommended for 128 patients (26%): 105 (22%) A&G alone and 23 input from community HF nurse specialists. Primary care management was recommended due to the following: presentation inconsistent with HF 53 (42%), more important competing comorbidity/frailty 35 (27%), recent assessment 17 (13%), and known HF 23 (18%). Patients managed in primary care had higher rates of all‐cause hospitalization (30% vs. 19%; P = 0.018) and death (7% vs. 2%; P = 0.0054) than those seen in HF clinic. Of those managed in primary care, 50 (39%) were determined to be at low risk and 78 (61%) at high risk. High‐risk patients were older (87 vs. 80 years; P = 0.0026), had much higher NTproBNP (2666 vs. 697 pg/mL; P < 0.0001), and were managed in the primary care due to severe comorbidity (45%) or known HF (31%). They had extremely high rates of adverse outcomes: 35 all‐cause hospitalization (45%), 12 HF hospitalization (15%), and 9 deaths (12%). Low‐risk patients were usually felt not to have HF (86%) and confirmed to have low rates of adverse outcomes: three all‐cause hospitalizations (6%; P < 0.0001 compared with high risk) and zero HF hospitalization (P = 0.0033) or death (P = <0.012).ConclusionsIncorporating specialist referral management into NICE HF diagnostic pathway reduces the demand on HF clinics and may improve the patient experience by facilitating community care. However, many of the patients identified for primary care management are at very high risk of adverse outcomes in the short term and are frequently hospitalized. Urgent implementation of alternative pathways and community‐based care packages in parallel for these high‐risk patients is extremely important.

Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme

Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme