Heart Failure Unit Research Articles

Impact of pharmaceutical care on hospital readmissions for heart failure: a randomised trial

ObjectivesTo evaluate the impact of pharmaceutical care on the number of readmissions and visits to the emergency department due to heart failure 30 days after hospital discharge, based on a...

Abstract 4119908: Outcomes for heart failure patients with reduced ejection fraction attending emergency department and discharged within 24 hours versus those admitted patients in heart failure unit.

Introduction: Heart failure (HF) is a clinical syndrome with increasing prevalence. Currently, there are extensive evidence-based therapies targeted at managing patients with heart failure and reduced ejection fraction (HFrEF) to improve outcomes. The National Heart Failure Audit shows the quality of inpatient care (specialist review, discharge medication etc) is related to outcome. This study aimed to evaluate the current practice at a London tertiary centre hospital in managing patients with heart failure and compared outcomes in patients who had a short course of admission (less than 1 day) with those who had a more prolonged course of admission. Method: Retrospective data was collected from a London tertiary centre hospital database for consecutive patients from Sep/2022 till Sep/2023. Statistical analysis was performed using Chi-Square test. The eligibility criteria included a new or previous diagnosis of HF with left ventricular ejection fraction (LVEF) < 40%. Patients were divided into two groups: Group A included 40 eligible patients who were admitted and discharged from the emergency department (ED) within 24 hours. Group B included 37 eligible patients who were admitted and discharged from the dedicated heart failure unit after 10-15 days of hospital admission. Results: In Group A, prescribing guideline-directed medical therapy (GDMT) was lower compared to Group B; Renin-Angiotensin-Aldosterone Inhibitors (47.50% vs. 94.59%), beta blockers (55% vs. 91.89%), mineralocorticoid receptor antagonists (12.50 %vs. 94.59%), and sodium-glucose co-transporter 2 inhibitors (15% vs. 89.19%). More patients in Group B received all four pillars of GDMT (86.49%) compared to Group A (5%). At 6-month follow-up,18.75% were on 4 GDMT in Group A versus 92% in group Group B. Re-admission within 6 months was higher in Group A (30%) compared to Group B (16.22%); however, the difference was not statistically significant (P value: 0.153). Higher mortality rates were observed in Group A (mortality rate: 20%) compared to Group B (mortality rate: 2.70%), with statistical significance (P value: 0.018). Conclusion: This study showed that HFrEF patients admitted to a specialist heart failure unit achieve higher rates of GDMT and have significantly improved outcomes compared to those who had a shorter inpatient stay and discharged from the emergency department. These findings underscore the high risks associated with rapid discharge from hospital on incomplete medical therapy.

Beating the clock: the impact of heart failure duration on CRT efficacy

Abstract Background Cardiac Resynchronization Therapy (CRT) stands as an established intervention for selected patients with heart failure (HF) presenting with a wide QRS complex. The optimal timing for CRT implantation remains uncertain. Current evidence suggests superior outcomes post-CRT in patients who have not been previously hospitalised for HF and those receiving the implant during their initial hospitalisation for HF.1 Purpose The primary objective of this study is to investigate the long-term clinical outcomes following CRT implantation relative to the duration of HF previous to the implant. It was analysed in a cohort of consecutive patients from a HF Unit who met the criteria for CRT as recommended by the ESC guidelines (QRS duration ≥150ms, left bundle branch block morphology, and left ventricular ejection fraction (LVEF) ≤35% despite optimal medical therapy). Methods We evaluated all patients who received CRT from January 2011 through September 2022. Follow-up ended in September 2023. Patients with CRT indicated for ventricular pacing due to high-degree atrioventricular block were excluded. Patients were categorized into two groups based on the duration of HF progression prior to CRT implantation: more than 3 years and 3 years or less. The primary outcome was all-cause mortality (ACM). Secondary outcomes included a composite of ACM and HF hospitalisation and the proportion of patients who demonstrated a significant improvement in LVEF (defined as an increase of ≥10% from baseline and a subsequent measurement of LVEF ≥40%). Results The cohort consisted of 127 patients, mean age 65.8±10.7 years, 23.6% were women, mean LVEF was 28.4±8.6% and 36.2% had ischaemic aetiology (Table 1). 62 patients either died or were hospitalized for HF. Mean follow-up was 4.9±2.7 years. After adjusting for age, sex and baseline LVEF, patients with HF for more than three years before CRT implantation had a worse prognosis: HRs of 2.31 for ACM (p=0.016) and 2.13 for the combined endpoint of ACM+HFH (p=0.010) (Figure 1). The proportion of patients with improved LVEF after CRT was significantly higher in the group with shorter HF duration (68.25%) compared to the group with longer HF duration (25%), p <0.001. Conclusions Our findings reveal that patients with a shorter history of HF (less than three years) prior to CRT implantation exhibit significantly better clinical outcomes. These results highlight the role of early intervention with CRT in patients with HF, suggesting that shorter HF duration prior to CRT may lead to more favourable long-term outcomes.

Automatic telephonic follow up in heart failure by a natural language processing artificial intelligence: pilot program

Abstract Introduction Heart failure (HF) burden on public health is substantial and efficient patient management strategies are needed. Traditional methods of HF monitoring face limitations in scalability and effectiveness. Artificial Intelligence (AI) might offer novel solutions for enhanced resource management and alleviation of healthcare burdens. Purpose To study the feasibility of implementing automatic remote monitoring via phone calls operated by AI in a HF unit. Methods We conducted a non-randomized, open, pilot trial employing an AI technology based on natural language processing for autonomous telephone outreach for the follow up of HF patients. 86 patients from a tertiary hospital HF unit undergoing pharmacological titration and education were enrolled. The AI conducted weekly calls to gather symptomatology, vital signs, and health status changes, which were then displayed on a virtual platform featuring alerts preconfigured by the research team. These alerts guided patient communication and intervention as deemed necessary by a specialized nurse. Results Characteristics of patients are shown in Table 1. The AI followed these patients for a median of 251.5 days. 2773 telephonic calls were performed. We estimate an equivalent to 1445h of work (17.2 days/month). Adherence was high during the study, with 98% of the calls completed. 1427 alerts were generated, being the most frequent weight change (251; 17.6%), orthopnea (220; 15.4%) and fatigue (187; 13.1%). It led to 487 remote interventions, most of them consisting in calling the patient for assessment (409; 84.0%), but also in adjusting medication remotely (34; 7.0%). See Figure 2. A HF telemedicine specialized nurse required 205min per week for alert review, 2.38min/patient-week. 2 patients died, one from cardiovascular causes, and 7 patients had a HF hospitalization, 42.9% with previous alarms. 20 events of worsening HF were recorded, comprising hospitalization, emergency visit or IV diuretic administration. Oral diuretic dose was increased in 22 occasions, 15 of them remotely in response to an alert raised by the AI operator. At 6 months functional class globally improved (p = 0.028), but NTproBNP increased (p=0.0472). Quality of life was evaluated at baseline and at 6 months, with no change in EQ5D5L (median 0.717, change -0.005, p 0.71) or PHQ4 (median 2.88, change -0.29, p 0.7792), but KCCQ12 total score worsened (median 74.49, change -2.32, p 0.048). Experience was rated with 8.97/10 in a satisfaction questionnaire. All patients recommended the program, remarking a closer follow up, better communication and a safety feeling. Conclusions AI enables closer monitoring of patients with HF, maintaining contact with stable patients while also allowing for resource allocation and tracking of higher-risk patients or those experiencing changes in symptoms. A randomized clinical trial comparing to standard follow-up is needed to evaluate this promising technology.Table 1Figure 2

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.

Up-titration of Guideline Directed Medical Therapy (GDMT) and the occurrence of side effects in Heart Failure with reduced Ejection Fraction (HFrEF)

Abstract Background The ESC Guidelines recommend early, full-dose use of heart failure (HF) medications to enhance survival, but real-world application often faces delays and inconsistencies. Clinicians often fear side effects during up-titration to the recommended target dose (TD), i.e. hypotension, bradycardia, renal impairment, and hyperkalemia (HK). The dependency of side effects during dose escalation from the severity of HF remains unclear. Purpose This study aimed to evaluate the relationship between the occurrence of side effects during up-titration of HF medication and HF severity reflected by N-terminal pro B-type natriuretic peptide (NT-proBNP). Methods 425 patients with HFrEF and a complete data set of patient characteristics, medications and laboratory values at baseline (BL), 2 months (2M), and 6 months (6M) were included from our outpatient HF unit's prospective registry. Significant side effects were defined as: systolic blood pressure (SBP) <90mmHg, heart rate (HR) <50 beats per minute (bpm), potassium (K) >5.0mmol/l or K >5,5mmol/l and estimated glomerular filtration rate (eGFR) <30ml/min/1.73m2. Patients were categorized into three risk groups based on their NT-proBNP levels, i.e. low-risk with NT-proBNP <1000pg/ml, medium-risk with NT-proBNP 1000-2000pg/ml or high-risk with NT-proBNP >2000pg/ml. The occurrence of side effects was recorded and the development compared among the HF risk groups. Results Figure 1 shows up-titration of HF medication. Mean daily dosages of betablockers (BB), mineralocorticoid receptor antagonists (MRA) and renin-angiotensin-system inhibitors (RASi) increased significantly during follow-up (BL vs 2M and BL vs 6M, p<0.001 for all). The majority of patients received ≥50% of the recommended TDs at 6M (89% for BB, 83% for MRA, 88% for RASi and 91% for total mean TDs ≥50%), and the achieved daily dosages at 6M were largely comparable across the HF risk groups at 6M, except for RASi (p=0.030). Figure 2 depicts the side effects. Side effects developed almost exclusively at short-term within 2M except for lower SBP (Figure 2A). Newly developed side effects occurring after up-titration (2B) were even more rare and predominantly occurred within the highest NT-proBNP group. The occurrence of hypotension and bradycardia was infrequent and comparable within the HF risk groups. Renal dysfunction (at 6M p=0,041) and HK occurred predominantly in higher risk patients (HK at 2M p=0,001 and at 6M p<0,001). Conclusions Up-titration of HF medications is highly feasible, particularly in low- and medium-risk patients. Despite rare side effects such as hyperkalemia and renal impairment, up-titration remains unimpeded, especially in patients with NT-proBNP levels below 2000pg/ml. These findings emphasize the safety of up-titration in HF.

Real-world eligibility for GLP1-ra therapy in a cohort of heart failure patients

Abstract Background GLP1-ra have demonstrated substantial cardiovascular (CV) benefits in diabetic and, more recently, non-diabetic patients, however their use in heart failure (HF) patients is still limited. Purpose To evaluate real-word eligibility to GLP1-ra in a cohort of HF patients. Methods Demographic and clinical data from HF patients evaluated at a single center HF unit from August 1st 2021 to November 29th 2023 were automatically retrieved from the electronic health record (EHR). Patients were deemed eligible to GLP1-ra based on (1) absence of ongoing treatment with GLP1-ra and (2) either having type 2 diabetes mellitus (T2DM) or satisfying the inclusion criteria of the SELECT trial or those of the STEP-HFpEF trial, which were adapted according to the available information. A sensitivity analysis lowering the body mass-index cut-off to >= 27 kg/m2 also for the STEP-HFpEF trial was performed. Results 1754 patients with an established diagnosis of HF were included; median age was 78.3 (IQR 70.7-83.8) years and 697 patients were female (39.7%). 6 patients had type 1 diabetes mellitus. Among the remaining 1749 patients, 633 (36.2%) patients had T2DM and 14 were already treated with GLP1-ra. Among 1116 patients without diabetes, 302 (27.1%) were eligible to receive GLP1-ra according to the inclusion criteria of the SELECT or STEP-HFpEF trials. 226 (20.2%) satisfied the SELECT trial inclusion criteria and among them 100 (44.8%) had HF with reduced ejection fraction, whereas 136 patients (12.2%) were eligible to receive GLP1-ra according to the STEP-HFpEF trial. Changing the BMI cut-off to >= 27 kg/mq, as in the SELECT trial, 219 patients (19.6%) according to the STEP-HFpEF inclusion criteria and 344 (30.8%) overall were found to be eligible for GLP1-ra therapy. Conclusion Real-word eligibility to GLP1-ra may reach up to 55% of HF patients according to diabetes status or trial inclusion criteria.

Heart failure and advanced chronic kidney disease: differences in characteristics, treatment and outcomes in patients with glomerular filtration rate greater or less than 30 ml/minute/m2

Abstract Introduction Heart failure (HF) is a serious health problem and continues to have a high mortality and incidence of decompensation, despite advances in its management. Chronic kidney disease (CKD) is very prevalent in patients with HF, hinders their treatment and worsens their prognosis, especially when it is advanced CKD (glomerular filtration rate-GFR <30 ml(min/m2). It is important to know the differential characteristics of these patients to improve their management. Purpose To analyze in a contemporary registry of HF patients followed in specialized HF units in Spain the differences in clinical characteristics and treatment between patients with HF and advanced CKD. Methods We analyzed data from the registry of the SEC-Excelente-IC quality accreditation program of the Spanish Society of Cardiology, with 1716 patients with HF included between 2019 and 2021 by 45 specialized HF units accredited by the SEC. Patients were included consecutively in two 1-month cutoffs (March and October) in that period. The clinical and demographic characteristics and comorbidities of the patients were compared according to GFR < or > 30ml/min/m2. Results Of the 1,716 patients, 11.1% had a GFR<30 and 88.9% >30 mL/min/m2. Figure 1 shows the main clinical characteristics and comorbidities of the 2 groups. Median LVEF was similar in both groups: 42 (30-58) vs 38% (29-54). The group with advanced CKD was older (77±9.6 vs 70.5±12.6 years; p<0.001), had greater HF severity (more admissions for HF in the last year, worse NYHA functional class and longer evolution time), and a higher prevalence of coronary heart disease, hypertension, diabetes mellitus, cognitive impairment, anemia, iron deficiency and hyponatremia. There were no differences in sex, BMI, serum potassium or other comorbidities (Figure 1). Figure 2 shows the treatment received in each group. Patients with GFR <30 received in a significantly lower proportion all drugs for HF (p<0.001), except diuretics and potassium binders (ACEI/ARA, sacubitril-valsartan, MRA, beta-blockers, digoxin and SLGT2 inhibitors), and less cardiac rehabilitation (5.2 vs 10.4%; p=0.029). Incidence of one-year mortality was significantly higher in patients with GFR<30 ml/min/m2 (37.2 vs 14.4 per 100 persons-year, p<0.001), as were HF hospitalizations (61.3 vs 33.0; p<0.001) and HF decompensations without hospitalization (24.1 vs 11; p<0.001). Conclusions In our contemporary cohort of real-life HF patients, the prevalence of advanced CKD was 11.1%. These patients had a higher severity of HF, despite which, the utilization of HF drugs, including SGLT2 inhibitors was much lower than in those with GFR >30 ml/min/m2. One-year mortality, HF hospitalization and HF decompensations were almost 3-times higher. This treatment trend needs to be modified to improve the prognosis of these patients.

Heart Failure Knowledge Assessment and Perceived Patient Satisfaction in Heart Failure Units: A Multicenter Observational Survey.

Self-care and empowerment promotion in patients with heart failure (HF) is essential for improving their prognosis, but there is limited information concerning the patients' depth of knowledge about this pathology as well as patient satisfaction within heart failure units (HFUs). Our objective was to assess both aspects in a cohort of patients regularly followed-up HFUs. A multicenter, observational study was conducted with consecutive patients followed in 14 HFUs between June and November 2023. It was based on a cross-sectional survey comprising 23 questions related to demographics, knowledge/self-care, and the subjective assessment of perceived quality and satisfaction in HFUs. 281 patients were included (36.7% women, 74.7% aged over 65 years). 48% had hospitalizations for HF or sought emergency department services within the preceding year. The mean correct responses related to knowledge were 9.7 ± 2.3 (80.7% of the total), and 53 patients (18.9%) answered all knowledge questions correctly. 211 (79.6%) could identify potential HF decompensation with abrupt weight gain, and 196 (74.2%) recognized at least three additional signs of worsening HF. 266 patients (98.2%) were likely or very likely to recommend HFUs, and 194 (89.8%) positively appreciated the experience at the day hospital. Patients followed up in HFUs showed adequate but improvable knowledge and capacity for self-care, with a high level of satisfaction.

Pathophysiology of the right ventricle and its pulmonary vascular interaction.

The right ventricle and its stress response is perhaps the most important arbiter of survival in patients with pulmonary hypertension of many causes. The physiology of the cardiopulmonary unit and definition of right heart failure proposed in the 2018 World Symposium on Pulmonary Hypertension have proven useful constructs in subsequent years. Here, we review updated knowledge of basic mechanisms that drive right ventricular function in health and disease, and which may be useful for therapeutic intervention in the future. We further contextualise new knowledge on assessment of right ventricular function with a focus on metrics readily available to clinicians and updated understanding of the roles of the right atrium and tricuspid regurgitation. Typical right ventricular phenotypes in relevant forms of pulmonary vascular disease are reviewed and recent studies of pharmacological interventions on chronic right ventricular failure are discussed. Finally, unanswered questions and future directions are proposed.

Retrospective Analysis of VA-ECMO in Cardiogenic Shock Patients Within the Advanced Heart Failure Unit in Western Australia: A 17-Year Review

Retrospective Analysis of VA-ECMO in Cardiogenic Shock Patients Within the Advanced Heart Failure Unit in Western Australia: A 17-Year Review

Outcomes of patients with heart failure followed in units accredited by the SEC-Excelente-IC quality program according to the type of unit

Introduction and objectivesThe development of specific heart failure (HF) units has improved the management of patients with this disease due to improved organization and resource management. The Spanish Society of Cardiology (SEC) has defined 3 types of HF units (community, specialized, and advanced) based on their complexity and service portfolio. Our aim was to compare the characteristics, treatment, and outcomes of patients with HF according to the type of unit. MethodsWe analyzed data from the SEC-Excelente-IC quality accreditation program registry, with 1716 patients consecutively included in two 1-month cutoffs (March and October) from 2019 to 2021 by 45 SEC-accredited HF units. We compared the characteristics, treatment and 1-year outcomes between the 3 types of units. ResultsOf the 1716 patients, 13.2% were treated in community units, 65.9% in specialized units, and 20.9% in advanced units. The rates of mortality (27.5 vs 15.5/100 patients-year; P<.001), admissions for HF (39.7 vs 29.2/100 patients-year; P=.019), total decompensations (56.1 vs 40.5/100 patients-year; P=.003), and combined death/admission for HF (45.2 vs 31.4/100 patients-year; P=.005) were higher in community units than in specialized/advanced units. Follow-up in a community unit was an independent predictor of higher mortality and admissions at 1 year. ConclusionsCompared with follow-up by more specialized units, follow-up in a community unit was associated with a higher decompensation rate and increased 1-year mortality.

Pronóstico de los pacientes con insuficiencia cardiaca seguidos en unidades acreditadas en el programa SEC-Excelente-IC con relación al tipo de unidad

Introduction and objectivesThe development of specific heart failure (HF) units has improved the management of patients with this disease due to improved organization and resource management. The Spanish Society of Cardiology (SEC) has defined 3 types of HF units (community, specialized, and advanced) based on their complexity and service portfolio. Our aim was to compare the characteristics, treatment, and outcomes of patients with HF according to the type of unit. MethodsWe analyzed data from the SEC-Excelente-IC quality accreditation program registry, with 1716 patients consecutively included in two 1-month cutoffs (March and October) from 2019 to 2021 by 45 SEC-accredited HF units. We compared the characteristics, treatment and 1-year outcomes between the 3 types of units. ResultsOf the 1716 patients, 13.2% were treated in community units, 65.9% in specialized units, and 20.9% in advanced units. The rates of mortality (27.5 vs 15.5/100 patients-year; P<.001), admissions for HF (39.7 vs 29.2/100 patients-year; P=.019), total decompensations (56.1 vs 40.5/100 patients-year; P=.003), and combined death/admission for HF (45.2 vs 31.4/100 patients-year; P=.005) were higher in community units than in specialized/advanced units. Follow-up in a community unit was an independent predictor of higher mortality and admissions at 1 year. ConclusionsCompared with follow-up by more specialized units, follow-up in a community unit was associated with a higher decompensation rate and increased 1-year mortality.

Optimizing the management of heart failure: structuring the care pathway

The incidence of chronic heart failure continues to rise in Western countries, justifying the implementation of an optimized multidisciplinary organization based on medical and nursing convergence. Around the main heart failure, assistance and transplantation unit at Toulouse University Hospital, several structures have been put in place to better manage heart failure patients and improve their care pathway.

Impacto pronóstico de la enfermedad pulmonar obstructiva crónica y el asma bronquial en pacientes con insuficiencia cardiaca

PurposeTo analyze the impact of chronic obstructive pulmonary disease (COPD) and bronchial asthma on therapeutic management and prognosis of patients with heart failure (HF). MethodsAnalysis of the information collected in a clinical registry of patients referred to a specialized HF unit from January-2010 to June-2012. Clinical profile, treatment and prognosis of patients was evaluated, according to the presence of COPD or asthma. Survival analyses were conducted by means of Kaplan-Meier and Cox's methods. Median follow-up was 1493 days. ResultsWe studied 2577 patients, of which 251 (9.7%) presented COPD and 96 (3.7%) bronchial asthma. Significant differences among study groups were observed regarding to the prescription of beta-blockers (COPD=89.6%; asthma=87.5%; no bronchopathy=94.1%; P=.002) and SGLT2 inhibitors (COPD=35.1%; asthma=50%; no bronchopathy=38.3%; P=.036). Also, patients with bronchial disease received less frequently a defibrillator (COPD=20.3%; asthma=20.8%; no broncopathy=29%; P=.004).COPD was independently associated with increased risk of all-cause mortality (HR=1.64; 95%CI: 1.33-2.02), all-cause death or HF admission (HR=1.47; 95%CI: 1.22-1.76) and cardiovascular death or heart transplantation (HR=1.39; 95%CI: 1.08-1.79) as compared with patients with no bronchopathy. Bronchial asthma was not significantly associated with increased risk of adverse outcomes. ConclusionsCOPD, but not asthma, is an adverse independent prognostic factor in patients with HF.

Achieving optimal doses in treatment of heart failure with reduced ejection fraction at Gia Dinh People's Hospital

Heart failure (HF) with reduced ejection fraction (HFrEF) is a complex clinical syndrome associated with high mortality, long hospital length of stay, high readmission rates, reduced exercise tolerance, and decreased quality of life, as well as requiring significant resources to support treatment and care 1. Currently, it is reported that approximately 50% of all heart failure cases are HFrEF. However, due to recent advancements in cardiovascular diagnostic imaging, earlier, and possibly more precise, detection of HFrEF is greatly enabled. Not only does this seemingly increase the incidence rate of HfrEF in the general population, but it also gives treatment facilities an advantage in improving the prognosis and average life expectancy for these newly rising cases of HFrEF 2. According to heart failure treatment guidelines by Heart Associations around the world, an effective, interdisciplinary, and coordinated care system needs to be applied to all heart failure patients, including the reduced ejection fraction heart failure group, in order to achieve optimal guidelinesrecommended therapy, reduce mortality and readmission. In addition, each patient needs to be provided with a detailed treatment plan, which comprises treatment goals, effective management of comorbidities, follow-up time, diet, and physical activity 6. Therefore, the critical role of HF management programs in improving symptoms and quality of life in both inpatient and outpatient settings has been well recognized and paid continuous attention for the last two decades, with regular updates on team-based healthcare systems and home-based patient care 8,9,10. Recent updates in treatment guidelines have highlighted the role of the treating physician in customizing and adjusting the therapeutic drugs’ doses, to match those recommended as target or optimal, which must also be well-tolerated by the patients, with the aim of improving clinical outcomes 12. Therefore, it could be deduced that not only the sheer application of the four evidence-based foundational treatment but also dose adjustment over time of each one, should be collectively recognized as the basis of treating patients with HFrEF. The operation of a highlyspecialized unit, solely dedicated to the management of HF, known as ‘Heart Failure Unit’, has proven its effectiveness, by means of optimization of medical therapy, irrespective of baseline EF, but most notably reduced EF. Therefore, patients’ symptoms and readmission rate in facilities with “Heart Failure Unit” has witnessed a noticeable reduction. In today’s Vietnam, many tertiary medical facilities have implemented such centralized heart failure care models, and the Cardiology Department of Nhan dan Gia Dinh Hospital is definitely not an exception. The Heart Failure Unit in our department has been established and operating with a soulful dedication to providing HF patients with utmost comprehensive care and guideline-recommended therapy.

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 &amp; 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 &amp; 46 patients completed follow-up of 3, 6 &amp; 12 months, respectively. Readmissions for HF were 50% lower over 1,3, &amp; 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 &amp; 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 &amp; 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.

HFrEF phenotyping in real life

Abstract Background In May 2021 an HFA position paper[1] by Rosano GMC et al. classified patients with heart failure with reduced ejection fraction (HFrEF) into 11 phenotypes based on blood pressure, heart rate, renal function, potassium level and rhythm and assigned them to different prescription attitudes. Aim We aim to investigate the distribution of phenotype frequency in our cohort and their respective outcomes. Methods From 2016 to 2022 we enrolled 900 advanced HFrEF patients with severely reduced ejection fraction (LVEF &amp;lt;35%) in a prospective registry from our tertiary care heart failure unit. Patients were grouped according to the suggested phenotypes. Distribution and outcome for the different groups was analyzed. Results Characteristics of the different phenotypes, the distribution and outcome are shown in Figure 1. 65.8% of patients belong to 5 categories [3, 4, 5, 7b and 9]. Baseline characteristics of these 5 profiles are shown in Table 1. With the exception of Profile 3, which is characterized by a low resting hear rate, these major profiles are all eligible to receive all 4 drugs with class I recommendation at maximal dosages (RASi, BB, MRA, SGLT2i). The 6 remaining categories, all with GDMT limiting features, comprise solely another 3.8% of patients [1.8%, 1.2%, 0.3%, 0.3%, 0.2%, 0%, for the categories 7c, 7a, 1, 2, 6, 8 respectively]. With 30.2% a significant proportion of patients could not be assigned to one profile exclusively mostly because they showed a combination of profile attributes. Thus, of all classifiable HFrEF patients, with 83.4% the majority has no GDMT limiting features and should receive full HFrEF therapy. All-cause mortality did not differ between patient phenotypes [4,5,7b and 9] and the others (p = 0.193), while uncategorizable patients had significantly worse survival (p&amp;lt;0.0001) (Figure 1c). Conclusion The study provides insight into heart failure phenotyping in a real-world setting. Most HFrEF patients are eligible for the 4 class I drugs of HFrEF medication, and only a minority may not be able to receive them. However, nearly one-third of all patients could not be categorized, including those with the poorest survival. Given these findings, the added value of the classification of patients according to this pattern seems limited in routine practice, possibly resulting from the complexity of the clinical picture of HFrEF.Figure 1 BL characteristics

Palliative care assessment and outcomes in patients admitted for heart failure in an Australian quaternary healthcare service

Abstract Background/Introduction Heart failure (HF) has high mortality and healthcare utilisation, and despite patients having similar palliative care needs to cancer patients(1), they are much less likely to have their PC needs assessed and managed (2-3). Expert consensus guidelines from cardiology and palliative care groups recommend early integration of a palliative approach in addition to usual care, but the complex and unpredictable trajectory of HF, lack of referral criteria and misunderstandings about PC are potential barriers that affect specialist PC referrals. Given the issues surrounding integration of PC in HF patients, we sought to understand the use of PC by patients with HF at our institution. Purpose To characterise the pattern and predictors of referrals of HF patients to the inpatient PC service in an Australian quaternary health service. Methods A single-centre retrospective cohort study was performed using electronic medical record data in consecutive patients admitted for HF at a quaternary health service in Australia, over a 12 month period from July 2019 to June 2020. All adults ≥ 18 years of age and admitted for HF were identified using the Diagnostic Related Group (DRG) admission code for ‘Heart Failure and Shock’. Results The 502 patients admitted for HF were elderly (median age 82 years, IQR 15) and 50% were male. Functional status was poor, with 29% unable to care for themselves and 56% requiring some level of assistance. General medicine was the major admitting unit with 67% (n=338 of 502) of patients, and the cardiology and advanced heart failure units admitted 12% (n=59) and 5% (n=26) of patients, respectively. Conversely, the main treating team in the ambulatory setting was cardiology in 51% (n=253). HF patients had high mortality rate at 32% during the median follow up time of 27 months (interquartile range 8 months). Seven percent (n=37 of 502) were referred to inpatient specialist PC, and often in the terminal phase. High dependency (defined as Australian-modified Karnofsky Performance Status 10-40) (62% vs 28%, p&amp;lt;0.01) and New York Heart Association class III-IV symptoms (86% vs 42%, p&amp;lt;0.01) were associated with referral, but one or more previous admission for HF in the last 12 months was not (35% vs. 28%, p=0.35). In all HF patients, symptoms were poorly assessed and discussion about prognosis occurred in 10% despite the high mortality. Referral to inpatient PC resulted in more prescribing of symptom medications on discharge (41% vs 2%, p&amp;lt;0.01) and referral to community PC (46% vs 1%, p&amp;lt;0.01). Conclusion Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients. In addition, treating teams do not routinely assess symptoms or discuss disease trajectory. More work is needed to ensure that HF patients’ PC needs are integrated into care as recommended by expert consensus.Table 1

The effect of long-term application of guideline-directed medical therapy on systolic blood pressure in hospitalized patients with heart failure with reduced ejection fraction

Abstract Background According to the current guidelines in heart failure (HF) with reduced ejection fraction (HFrEF) the implementation and titration of guideline-directed medical therapy (GDMT) is recommended. Although just symptomatic hypotension is known as a factor limiting the initiation or uptitration of GDMT, in everyday practice asymptomatic hypotension often has a negative impact on the long-term application of GDMT in HFrEF, even though patients with lower systolic blood pressure (SBP) have worse prognosis. Aim To assess the application of combined neurohormonal antagonist therapy (triple therapy [TT]: RASi[ACEi/ARB/ARNI]+βB+MRA) based on SBP during an index HF hospitalization, and to evaluate the long-term application of TT on SBP and on mortality. Patients and methods: The data of 247 consecutive HFrEF patients (male:75%, age:66[56-74]years, ischemic:46%, diabetes:40%, hypertension:63%, atrial fibrillation:46%, LVEF:25[20-30]%, eGFR:58[39-73]ml/min/1.73m2,SBP:118[102-134]mmHg) were analysed retrospectively, who had been admitted to the HF Unit of our tertiary centre due to HF in 2019-2021 and then were followed up for one year. Patients were divided into three SBP categories based on SBP measured at admission: SBP1:&amp;lt;100mmHg (n = 46), SBP2:100-120mmHg (n = 98), SBP3:&amp;gt;120mmHg (n = 103) (respectively). The applicability of TT at hospital discharge and at 1 year were assessed comparing SBP categories with Chi-square test. The changes of SBP within each category were compared with Wilcoxon test. 1-year all-cause mortality (ACM) was investigated with Kaplan-Meier method and log-rank test. Results At discharge, 77% of the patients received TT in the total cohort. Lower SBP at admission led to lower application ratio of βB (72-89-87%, p = 0.019), while RASi and MRA use was consistent across SBP categories (87-89-89%; 91-98-93%, p&amp;gt;0.05). TT application at discharge did not differ significantly among the subgroups (65-81-79%, p = 0.107). 1-year ACM was 23% in the total cohort, with significantly higher mortality rates in lower SBP groups (33-27-15%, p = 0.022). At 1 year TT application remained high; 65% in SBP1, 78% in SBP2 and 72% in SBP3 group. No differences (p&amp;gt;0.05) were seen in terms of βB (87-88-91%), RASi (81-89-84%) and MRA use (77-86-82%) in SBP groups. In the effect of GDMT, in the SBP1 and SBP2 group, SBP significantly (p&amp;lt;0.0001) rose (SBP1: from 92[85-95] to 110[95-127]mmHg, SBP2: from 111[104-117] to 124[110-133]mmHg; discharge vs. 1 year), while in the highest SBP group significant decrease was verified (from 137[129-146] to 130[118-145]mmHg, p = 0.002). Conclusions Our study results confirmed that low SBP is associated with a poor prognosis in HFrEF. Low SBP is a relevant influencing factor of GDMT initiation and long-term application, even though among these patients increase in SBP can be expected due to the use of GDMT. Our results indicate that low SBP should not make physicians be hesitant to optimize therapy in severe HFrEF.