Reduction In Heart Failure Admissions Research Articles

A virtual heart failure ward in a rural demography

Abstract Background Lincolnshire is a large rural county in the UK with wide economic variation, social deprivation, poor communication infrastructure and no large urban centre of population. As a result of these factors we have a significant incidence of heart failure and a variation in access to services. As part of a county wide initiative to improve the care of patients with heart failure and to reduce acute reduce admissions to hospital we introduced a virtual heart failure ward in January 2022. The ward is overseen by the community cardiology heart failure specialist nurses and led by a cardiology Advanced Clinical Practitioner (ACP) - a multi-professional worker educated to Level 7 with the ability to prescribe and request procedures/ investigations. Governance is from the acute cardiology team via multi-disciplinary meetings. Patients who are decompensating that historically would have required admission can be 'admitted' to the ward and patients who have been admitted to the acute hospital can also be admitted/ stepped down to facilitate discharge. The ward is supported by a 7/7 (expanded from 5/7 to support the project) specialist nursing team, weekly ward rounds, telemedicine (multi-provider app), remote monitoring (oximetry/ weight/ BP), outpatient IV furosemide, specialist heart failure rehabilitation (F2F and remote) and supports a seamless service between primary, community and secondary care. Results In the first 13-months N=213 patients were treated via the virtual ward. N=137 (64%) 'step up, N=75 (35%) step down, N=1 (self-referral), see figure one. N=194 patients were discharged. N=25 (12%) were admitted for escalation of care, see figure two. In the first year, we estimate that the virtual ward released 1,147 acute bed days (1,033 admission prevention and 114 early discharge) and delivered a cost reduction of approximately to £1m. An external audit team has identified a 10% reduction in heart failure admissions to the acute hospital. PROMS (patient recorded outcome measures) show high patient satisfaction and staff have found the enhanced 7/7 service beneficial and rewarding. Discussion Our experience of implementing a virtual heart failure ward in a rural demography has been exceedingly positive. We have observed significant reductions in admissions, facilitated early discharged from hospital with high patient and staff satisfaction. this intervention has also delivered a substantial cost saving to the wider health economy.Step Up/ Step DownDischarge Destinations

JCS/JHRS 2021 guideline focused update on non-pharmacotherapy of cardiac arrhythmias.

JCS/JHRS 2021 guideline focused update on non-pharmacotherapy of cardiac arrhythmias.

Insights into heart failure hospitalizations, management, and services during and beyond COVID-19.

Coronavirus disease 2019 (COVID‐19) is caused by severe acute respiratory syndrome coronavirus‐2. The clinical presentation of this virus mainly manifests in the respiratory system but may also lead to severe complications in the cardiovascular system. The global burden of COVID‐19 has led to an unprecedented need to gain further insight into patient outcomes, management, and clinical practice. This review aims to provide an overview of the current literature on heart failure (HF) hospitalizations, management, and care pathways for supporting patients during and beyond this pandemic. A literature review of five areas of interest was conducted and included: (i) HF hospitalization; (ii) recognizing the needs and supporting HF patients during COVID‐19; (iii) supporting rehabilitation services; (iv) transitioning to a telehealth framework; and (v) the need for evidence. Patients with new‐onset or existing HF are particularly vulnerable, but a significant reduction in HF hospital admissions has been reported. During these periods of uncertainty, the current care pathways for acute and elective cardiac patients have had to change with the relocation of HF services to protect the vulnerable and reduce transmission of COVID‐19. Optimizing community HF services has the potential to reduce the pressures on secondary care during the recovery from this pandemic. Telemedicine and virtual health care are emerging technologies and overcome the risk of in‐person exposure. Successful remote delivery of cardiac rehabilitation services has been reported during the pandemic. Delivery of a robust telehealth framework for HF patients will improve communication between clinician and patient. The reduction in HF admissions is a concern for the future and may result in unintended mortality. New‐onset and current HF patients must understand their diagnosis and future prognosis and seek help and support using the appropriate platform when needed. Realigning HF services and the use of telemedicine and virtual health care has great potential but needs to be carefully understood to ensure engagement and approval in this population to overcome barriers and challenges.

Abstract 13289: Incidence of Heart Failure Hospital Admissions Among Type 2 Diabetes Mellitus Patients and the Potential Impact of SGLT2 Inhibitors in Japan: A Population-based Study From the Shizuoka Kokuho Database

Introduction: Recent large-scale clinical trials have shown that the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduces the risk of cardiovascular (CV) events, particularly heart failure (HF) hospitalizations, in type 2 diabetes mellitus (T2DM) patients with established CV disease. We aimed to assess (1) the incidence of HF admissions, and (2) the potential reduction in HF admissions with the further introduction of SGLT2i, in a contemporary large administrative claims database in Japan. Methods: We selected patients aged ≥40 years, without previous HF diagnosis, who newly initiated oral antidiabetics in Shizuoka Kokuho Database between 2013 and 2018. We estimated the 5-year cumulative incidence of hospitalization for HF, myocardial infarction (MI), and stroke, treating death as a competing risk. Among the subgroup of patients with laboratory data, we identified patients meeting the inclusion criteria for EMPA-REG OUTCOME (EMPA-REG) or DECLARE-TIMI 58 (DECLARE) regarding HbA1c, eGFR, and CV disease. We estimated the number of events that can be reduced if they benefited the same risk reduction from the trials. Results: Among 23,340 oral antidiabetic drug initiators (46.0% women, 21.9% ≥75 years old) included, 2.6% were initiated on SGLT2i. The 5-year cumulative incidences of hospitalization for HF, MI, and stroke were 5.4% (95% confidence interval: 4.9-5.9%), 1.9% (1.7-2.2%), and 6.1% (5.7-6.6%), respectively. Among 6192 patients with laboratory data, 651 (10.5%) and 2680 (43.3%) patients met the EMPA-REG-like and DECLARE-like criteria, respectively (Figure). The 5-year cumulative incidence among the 2849 patients meeting either of the criteria was estimated to decrease from 97.1 to 75.2 events via 75% adoption of SGLT2i. Conclusion: The burden of HF among Japanese T2DM patients was high, almost equivalent to stroke. Increased use of SGLT2i among patients with high CV risk may significantly reduce its disease burden.

Sacubitril-Valsartan in a routine community population: attention to volume status critical to achieving target dose.

AimsIn the PARADIGM‐heart failure trial, sacubitril‐valsartan demonstrated a reduction in heart failure admissions and reduced all‐cause mortality in patients with heart failure with reduced ejection fraction. Although real world data have shown similar benefits regarding efficacy and safety, there has been difficulty in achieving the target dose (TD). The factors preventing the achievement of TD remains unclear.This study assesses the tolerability, ability to achieve, and factors linked to attaining TD in a routine clinical population.Methods and resultsThis is a retrospective single‐centre review of patients switched from angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers to sacubitril‐valsartan between May 2016 and August 2018. Baseline and follow‐up clinical characteristics and biomarker profiles were collected. Univariate and multivariate analyses were used to analyse predictors of achieving TD. Clinical response to sacubitril‐valsartan was defined as a reduction in N terminal pro BNP of ≥30%, or an increase in left ventricular ejection fraction of ≥5% compared with baseline values.To date, a total of 322 patients (75% male patients) have been switched to sacubitril‐valsartan. Those still in the titration phase were excluded (n = 25). Sacubitril‐valsartan was not tolerated in 40 patients (12.4%). Those intolerant were older (73.4 years [68.3, 80.6] vs. 69.1 years [61.2, 76]; P = 0.003) and had worse renal function with estimated glomerular filtration rate (53.5 mL/min/1.72 m2 [36.8, 60.2] vs 60 mL/min/1.72 m2 [47, 77]; P ≤ 0.001). Of the remaining 257 patients, TD (97/103 mg BD) was achieved in 194 patients (75.5%), while 37 patients (11.4%) were maintained on 49/51 mg BD and 26 patients (8.1%) remained on 24/26 mg BD. Symptomatic hypotension (74.6%) was the main impediment to attaining TD, followed by renal deterioration (12.7%), and to a lesser extent hyperkalaemia and gastrointestinal symptoms (4.8% each). Diuretic dose decrease was achieved in 37.2% of patients, and this was the strongest independent predictor of achieving TD (odds ratio = 2.1; 95% confidence interval [1.16, 3.8]; P = 0.014). Responder status by N terminal pro BNP criterion was observed in 99 of 214 patients (46.3%) while 70 of 142 (49.3%) attained the left ventricular ejection fraction response status. Achieving this response was independently linked to achieving TD.ConclusionsSacubitril‐valsartan was well tolerated. Achievement of TD was possible in the majority of the cohort and was linked to response metrics. Reduction in diuretic was required in a large percentage of the population and was the strongest predictor of attaining TD. Therefore, careful clinical attention to volume status assessment is essential to maximising the benefits of sacubitril‐valsartan.

CardioMems® device implantation reduces repeat hospitalizations in heart failure patients: A single center experience.

IntroductionHospital readmission for congestive heart failure remains one of the most important economic burdens on healthcare cost. The implantation of a wireless pressure monitoring device (CardioMEMS®) had led to nearly 40% reduction in readmission rates in the landmark CHAMPION trial. We aim to study the effectiveness of this wireless device in reducing heart failure admissions in a real-world setting.MethodsThis is a retrospective chart review of patients with recurrent admissions for heart failure implanted with the wireless pressure monitoring system (CardioMEMS®) at our institution. We studied the total number of all-cause hospital admissions as well as heart failure-related admissions pre- and post-implantation.ResultsA total of 27 patients were followed for 6–18 months. The total number of all-cause hospital admissions prior to device implantation was 61 admissions for all study patients, while the total number for the post-implantation period was 19, correlating with 2.26 + 1.06 admissions/person-year prior to device implantation versus 0.70 + 0.95 admissions/person-year post-implantation (p-value < 0.001). For heart failure-related admissions, the total number prior to device implantation was 46 compared to 9 admissions post device implantations, correlating with 1.70 + 1.07 admissions/person-years pre-implantation versus 0.33 + 0.62 admissions/person-years post-implantation (p-value < 0.001). This translates to 80.4% and 68.9% reduction in heart failure and all-cause admissions, respectively.ConclusionIn a real-world setting, the implantation of a wireless heart failure monitoring system in patients with heart failure and class III symptoms has resulted in 80.4% reduction in heart failure admissions and 69% reduction in all-cause admissions.

Real World Analysis of Efficacy of CardioMEMSTMHF System Guided Heart Failure Management Comparing Patients with Reduced and Preserved Ejection Fraction

Background Previous studies reported that nearly 50% of patients hospitalized with decompensated heart failure (HF) have preserved left ventricular ejection fraction (EF). Objective We aimed to look at the efficacy of remote hemodynamic monitoring in our center using CardioMEMSTMHF system in reducing the hospital and clinic encounters in patients with HF with reduced EF (HFrEF) versus HF with preserved EF (HFpEF). Methods We performed a retrospective analysis of 106 sequential patients who received CardioMEMS device from April 2015 to January 2018. We divided these patients into two groups based on the EF. We collected data on the number of HF admissions, total hospital admissions, and clinic visits 1-year prior and 1-year after the device implantation. Time to death (in years) were calculated post-implant in all patients. Results Our study showed a significant reduction in HF admissions per year from 4.01 ± 7.56 to 0.88 ± 1.34 (p = 0.0353), total admission per year from 4.87 ± 7.96 to 2.00 ± 2.35 (p = 0.0110) and clinic visits per year from 7.07 ± 9.45 to 5.20 ± 3.27 (p = 0.0071) in patients with HFrEF. There was an overall decrease in the hospital and clinic encounters in patients with HFpEF, but it was not statistically significant. However, there was no significant difference in the outcomes in patients with HFrEF versus HFpEF post-implant ( Table 1 ). Time to death in years in HFrEF cohort post-implant was 0.98 ± 0.54and in the HFpEF post-implant was 0.65 ± 0.75and this was not statistically significant. Conclusion There was a statistically significant reduction in total admissions, HF admissions and clinic visits per year in patients with HFrEF post-implant. But there was no significant difference in these clinical outcomes compared to patients with HFrEF versus HFpEF post-implant.

Sustainable Improved Clinical Outcomes Using CardioMEMSTMHF System Remote Pulmonary Artery Pressure Monitoring in Treating Heart Failure Patients

Background CardioMEMSTMpulmonary artery pressure sensor had shown decreased rates of heart failure (HF) hospitalizations and quality of life compared to standard of care alone in the CHAMPION trial. Objective With our growing HF population, requiring CardioMEMSTM implant in our center based on the FDA approved indication, we aimed to look at the differences in HF admissions, total hospital admissions, clinic visits in all patients. We also aimed to evaluate if there was a difference in these outcomes between first 53 and second 53 patients with increasing operator and HF team experience. Time to death post-implant was also assessed. Methods We performed a retrospective analysis of 106 sequential patients who received the implant. We collected data on number of HF admissions, total hospital admissions, and clinic visits 1-year prior and 1-year post-implant. Time to death (in years) were calculated post-implant in all patients. We labeled first 53 cohort as patients who received implant before Aug 2016 and second 53 cohort who received implant after Aug 2016. Results Our study showed a significant reduction in HF admissions, total admissions and clinic visits per year in all patients who received the implant ( Table 1 ). However, further analysis did not show a significant difference in these outcomes in the first 53 patients cohort versus second 53 patients cohort despite the HF population requiring the implant are growing ( Table 2 ). The second 53 patients showed significant reduction in each individual outcome. There was no statistically significant difference in post-implant death comparing these two groups. Overall there was a significant mean (%) reduction in each clinical outcome in all patients and comparing first 53 patients versus second 53 patients. Conclusion A significant reduction in HF admissions, total admissions and clinic visits per year in all patients who received the implant, especially in the second 53 patients. However, considering post-implant results, there were no significant differences in outcomes compared to the patients who received the implant before Aug 2016 versus after Aug 2016 and our results were sustainable.

Has the Time Come to Be More Aggressive With Bariatric Surgery in Obese Patients With Chronic Systolic Heart Failure?

Obesity is a strong risk factor for the development of heart failure (HF). Diet, exercise, and weight-loss pharmacotherapies have limited potential to achieve significant and sustainable weight loss, especially in patients with symptomatic systolic HF. This review seeks to determine the role of bariatric surgery for patients with systolic HF and obesity. Bariatric surgeries such as the laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) represent the most successful long-term strategy for achieving weight loss and diabetes and hypertension remission in the general obese population. These benefits translate to reductions in cardiovascular events and mortality, as well as improvements in myocardial structure and function. There is also now data supporting the safety of LSG or RYGB in patients with systolic dysfunction and a reduction in HF admissions post-operatively. Current literature and clinical experience suggest that the most appropriate bariatric surgery candidates with HF are patients aged < 50-60years, with severely depressed systolic function and NYHA II-III symptoms, who have failed non-surgical strategies and have a high likelihood of future cardiac transplantation candidacy after weight loss. This review seeks to determine the role of bariatric surgery for patients with systolic HF and obesity.

Role of a multidisciplinary program in improving outcomes in cognitively impaired heart failure older patients

Cognitive impairment (CI) frequently complicates Heart failure (HF) and is associated with increased mortality and morbidity. Previous studies reported that nurse-lead home-based multidisciplinary program (MP) may not improve the prognosis of this high-risk group. In the present study, we analysed the relative effectiveness of an integrated hospital-based MP in patients with cognitive impairment. Consecutive (n = 173) community-living outpatients aged > 70 years (mean 77 +/- 6, 48% women) randomized to a MP (n = 86) or usual care (UC) (n = 87) were enrolled in stable clinical conditions. Cognitive status was assessed by means of Folstein Mini Mental State Examination (MMSE). CI (MMSE < or = 24) was present in 41.6% (42,5% UC vs 40.7% MP p =ns). The variables independently associated to CI were: older age, education level <5 years, anemia and severe renal dysfunction. During a 2-year follow-up, 59 patients died (31.4%) with no significant difference between intervention group. At multivariate analysis, in the entire cohort, CI was independently associated to death (HR 2,07 7[95%CI 1,097-3,931]), HF admissions (2,133[1,346-3,381]), death/HF admissions (1,784[1,132-2,811]) and all-cause admissions (1,473[1,008-2,153]. When considered according to intervention groups, CI was independently associated to all-cause death (3,603 [1,553-8,358], death/HF admissions (2,029[1,200-3,432]) and HF admissions (2,474[1,406-4,353]) but not to all-cause admissions. The assignment of patients with CI to MP was associated to a significant reduction in HF admissions vs UC (0,503[0,253-0,999] (all interaction tests p = ns). This study suggests that CI is very common and associated to worse prognosis in heart failure and that hospital-based MP seems to improve outcomes in these patients through reduction of heart failure hospital admission.

Alpha-1 Adrenoceptor–Angiotensin II Type 1 Receptor Cross-Talk and Its Relevance in Clinical Medicine

The two most relevant clinical trials investigating the efficacy of multiple neurohormonal drug combinations in the treatment of chronic congestive heart failure are the Valsartan Heart Failure Trial and the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity-added studies. The Valsartan Heart Failure Trial study randomized patients with congestive heart failure to the angiotensin receptor blocker (ARB) valsartan versus placebo, in addition to baseline angiotensin-converting enzyme inhibitor (ACE-I) therapy. Overall, valsartan was found to significantly reduce the combined morbidity and mortality end point compared with placebo, mainly due to a reduction in heart failure admissions. However, a subgroup analysis showed that patients receiving triple therapy with valsartan, an ACE-I and a β-adrenoceptor blocker, appeared to do worse. These findings led to speculation that "triple therapy" with ARB, ACE-I, and nonselective β-blocker might be harmful, possibly due to excessive neurohormonal inhibition. In contrast, in the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity-added study, the "triple therapy" combination of ARB, ACE-I, and β-adrenoceptor blocker was proven safe and beneficial. We propose that the discrepancy in outcomes observed in these two trials is related to the interaction between the α1-adrenoceptor and the angiotensin II type-1 receptor, and it is not just an inherent adverse event related to "triple therapy."

Hospitalizations for Heart Failure in the United States—A Sign of Hope

HEART FAILURE (HF) IS THE MOST COMMON CAUSE OF hospitalization in patients older than 65 years in the United States. In the early 1990s, data from clinical trials and registries demonstrated that in patients hospitalized with HF, mortality and rehospitalization rates could be as high as 15% and 30%, respectively, at 60 to 90 days after discharge. During this period, major efforts were directed toward reducing the length of stay in patients hospitalized with HF. Performance measures were developed and later adopted by the Centers for Medicare & Medicaid Services (CMS) with the intent to improve postdischarge outcomes. Although these measures were implemented across the country, the rehospitalization rate for patients with HF did not appear to decrease. Recently, because of changes in CMS reimbursement patterns, the focus has shifted toward 30-day postdischarge readmission rates as a measure of care. In this issue of JAMA, Chen et al reviewed administrative data of more than 55 million Medicare fee-for-service beneficiaries,withameanageof79years,whowerehospitalizedwith a discharge diagnosis of HF. Black patients represented 11% of the total studypopulation.Theoverall ratesof risk-adjusted hospitalizationforHFdeclined30%over thestudyperiodfrom 2845 per 100 000 person-years in 1998 to 2007 per 100 000 person-years in2008.Theauthorsattribute thisdecline inhospitalizations to reductions in the incidence of coronary artery disease, improved control of blood pressure, increased use of evidence-based therapies, and possibly changes in admission thresholds. In contrast to this significant reduction in hospitalizations forHF,1-year risk-adjustedall-causemortality rate declined minimally but remained high at approximately 30%. This report is a substantial contribution to existing HF epidemiological literature because it is the first to document an improvementinhospitalizationrates inHFintheUnitedStates. These improvementsappear tobemoreevident inrecentyears during which major progress has been made in promoting evidence-basedtherapies forcoronaryarterydisease.However, thissubstantialdecline inhospitalizationrateswassignificantly less in black men than in white men. Another important observation was that the decreases in hospitalization rates across states were not uniform. The authors also noted that comorbidities such as hypertension and renal dysfunction increased over time. Approximately 40% of these patients had diabetes and 30% had chronic obstructive pulmonary disease. The general reduction in admission rates may reflect improvements in overall management of HF risk factors, as suggested by Chen et al, but the persistently high 1-year mortality rates suggest that postdischarge practices for patients with HF have not been as effective. Although the admission rates for HF have decreased based on Medicare data reported by Chen et al, the available data suggest that rehospitalization rates after an index admission for HF have remained unchanged or have even increased over a similar time frame. It is important to recognize that among patients discharged following hospital admission for HF, a significant number of rehospitalizations are not related to HF. In the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome StudywithTolvaptan) trial conducted inpatientsadmitted for worsening HF with reduced ejection fraction, the total rehospitalizationrateexceeded50%at9.9months,andless thanhalf of rehospitalizations were due to HF. This occurred despite the studypopulationbeing relativelyyoung forHF(meanage, 62years),withfewmajorcomorbidconditions.IntheDIG(Digitalis Investigation Group) ancillary trial that studied outpatients with HF and preserved ejection fraction, the total hospitalization rate exceeded 65% during a mean follow-up of 37 months.Ofthesehospitalizations,only35%wererelatedtoHF. Inbothstudies,totalcardiovascularhospitalizationsrepresented a large proportion of the hospitalizations. Targeting total rehospitalization rather than rehospitalization for HF rates may be especially important given the aging population and their associated cardiac and noncardiac comorbid conditions. Chen et al suggested that the reduction in HF admissions may be related to changes in the threshold for admission in emergency departments. Lee et al reported that patients with HF who were discharged home directly from the emergency department, representing 30% of total HF presentations in their cohort, had a high risk-adjusted early death compared with patients who were admitted. If the reduction in number of hospitalizations noted by Chen et al is

Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study

Disease management programs (DMP) improve outcomes in patients with heart failure. Because older heart failure patients represent a heterogeneous population, the aim of this study was to determine which patients benefit mostly from a DMP, by means of their frailty profile. Heart failure outpatient clinic. Consecutive (n = 173) patients aged more than 70 years were randomized to a multidisciplinary DMP (n = 86) or usual care (n = 87). A modified frailty score (range 1-6) was used as an index of global functional impairment. Mild to moderate frailty (frailty score = 2-3) was associated with significant improvements in outcomes (death and/or heart failure admission, heart failure admissions and all-cause admissions) in DMP patients vs. usual care. Even in more frail patients (frailty score = 4-6) a significant reduction in heart failure admissions was observed. By contrast, nonfrail patients (frailty score = 1) did not derive significant benefit. In the cost-effectiveness analysis, the mean savings per patient, stratified according to their frailty score, were -1003.31 euro for frailty score 1 (95% confidence interval -3717.00-1709.00), 1104.72 euro for frailty score 2 (-280.6-2491.00), 2635.42 euro for frailty score 3 (352.60-4917.00, P = 0.025) and 419.53 euro for frailty score 4-6 (-1909.00-2749.00). Intervention was therefore significantly cost saving in moderately frail, but not in nonfrail or severely frail patients. Thus, DMP was dominant (i.e. both less costly and more effective than usual care) in moderately frail patients. At sensitivity analysis, DMP remained dominant even to changes in cost of intervention and hospitalizations. This suggests that an intensive, hospital-based DMP appears to be more effective in older patients with mild-to-moderate levels of frailty. Thus, a multidimensional assessment of frailty seems to be a useful tool for appropriate selection of model of care.