Specialist Heart Failure Clinic Research Articles

Reduction of heart failure guideline-directed medication during hospitalization: prevalence, risk factors, and outcomes.

Optimal management of heart failure with reduced ejection fraction (HFrEF) includes titration of guideline-directed medical therapy (GDMT) to the highest tolerated dose within the licensed range. During hospitalization, GDMT doses are often significantly altered, although it is unknown whether the cause of hospitalization influences this. We recruited 711 people with stable HFrEF from specialist heart failure clinics and prospectively assessed events occurring during first unplanned hospitalization. Dose changes of ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), beta-blockers, mineralocorticoid receptor antagonists, and loop diuretics were recorded during 414 hospitalizations, categorized as due to decompensated heart failure, other cardiovascular causes, infection, or other non-cardiovascular causes. Most hospitalizations resulted in no change to GDMT. ACEi/ARB dose was reduced in 21% of hospitalizations and was more common during non-cardiovascular hospitalization (25.4% vs. 13.9%; P=0.005). ACEi/ARB dose reduction was associated with older age and lower left ventricular ejection fraction at study recruitment, and poorer renal function, lower systolic blood pressure, higher serum potassium, and less frequent care from a cardiologist during admission. People experiencing ACEi/ARB reduction had worse age-adjusted survival after discharge, without differences in heart failure re-hospitalization. De-escalation of beta-blockers occurred in 8% of hospitalizations, most often due to other non-cardiovascular causes; this was not associated with post-discharge survival or re-hospitalization with heart failure. De-escalation of HFrEF GDMT is more common during non-cardiovascular hospitalization and for ACEi/ARB is associated with reduced survival. Post-discharge care plans should include robust plans to consider re-escalation of GDMT in these cases.

Telemedicine reduces long term mortality in patients with heart failure with reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Telemonitoring was introduced with the potential to improve the medical care, quality of life and prognosis of patients with heart failure (HF). The aim of the study was to assess the effect of home telemedicine (HTM) in long-term mortality in patients with heart failure with reduced ejection fraction (HFrEF). Methods This is a retrospective study of 452 consecutive subjects with HFrEF who were referred to HTM service. The HTM service was offered to HFrEF patients who: a) have been recently diagnosed with HF, b) have been recently hospitalized due to HF, c) have worsening HF, d) need frequent medication changes, e) are NYHA class II or III. Most patients (n= 352) accepted HTM (HTM-group), but 100 patients refused and received the usual care (UC-group). The HTM group were assessed daily by body weight, blood pressure and heart rate using electronic devices with automatic transfer of data to an online database. A nurse practitioner evaluated the measurements every day using a dedicated clinical user interface. Clinical alerts are dealt with by the HTM nurse calling the patient and then, if necessary, a clinical responder; either a community HF nurse with prescribing qualifications or a cardiologist if long-term changes in therapy are required. Patients in both groups were seen at a specialist HF clinic and the frequency of clinical follow-up was at the discretion of the HF team. The same cardiologists reviewed the patients in both groups. Follow-up period was 60 months. Higher prevalence of male gender was seen in the UC-group (78% vs 67%, p = 0.03). Otherwise there was no significant difference in the demographic characteristics or primary cause of HF between the two groups. Also no differences were seen between the two groups in the treatment with beta blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers and aldosterone antagonists. Results The mean follow-up period for survivors was significantly higher in HTM-group compared with UC-group (50.6 ± 18.2 vs. 37.8 ± 25.2, p < 0.001). After 3 month of follow-up, the all-cause mortality was significantly lower in HTM-group than in UC-group (2.8% vs. 14%; p <0.01). This significantly lower mortality in HTM-group compared to UC-group was further observed in 6 months follow-up ( 4.5% vs. 22%, p < 0.0009); in 12 months follow-up (9% vs. 31.2%, p < 0.0002); in 18 months follow-up (13.4% vs. 38.2%, p < 0.0001); in 24 months follow-up (15.1% vs. 42%, p < 0.0001); in 36 months follow-up (19% vs. 44.5%, p < 0.0002); in 48 months follow-up (23% vs. 46%, p < 0.001); and finally in 60 months follow-up (25.3% vs. 46%, p < 0.003). Conclusion HTM was associated with improved survival. This was observed from the first months of the study and remained present until the end of the study.The reduced mortality in the HTM patients may reflect the fact that HTM improves patient HF knowledge and self-care behaviors.

Urinary drug metabolite testing in chronic heart failure patients indicates high levels of adherence with life-prolonging therapies.

AimsDespite medical therapy for heart failure (HF) having proven benefits of improving quality of life and survival, many patients remain under‐treated. This may be due to a combination of under‐prescription by medical professionals and poor adherence from patients. In HF, as with many other chronic diseases, adherence to medication can deteriorate over time particularly when symptoms are well controlled. Therefore, detecting and addressing non‐adherence has a crucial role in the management of HF. Significant flaws and inaccuracies exist in the methods currently used to assess adherence such as patient reporting, pill counts, and pharmacy fill records. We aim to use high‐performance liquid chromatography–tandem mass spectrometry (HPLC‐MS) to detect metabolites of HF medications in the urine samples of chronic HF patients.Methods and resultsUrine samples were collected from 35 patients in a specialist HF clinic. Patients were included if they had an ejection fraction <45% and were taking at least two disease‐modifying HF medications. They were excluded if they had been admitted to hospital for HF in the 3 months preceding clinic attendance. These samples were sent for HPLC‐MS and tested for all HF medications prescribed for that patient. A high rate of complete adherence of 89% was detected in these patients, with 94% being partially adherent (at least one HF medication detected) to therapy (at least one HF medication detected). This analysis also highlighted that mineralocorticoid antagonists represent both the most under‐prescribed (67%) and poorly adhered (75%) medication class.ConclusionsThis analysis revealed a surprisingly high level of adherence to disease‐modifying therapy in chronic HF patients and highlights that most of our ‘total’ under‐treatment is likely to be from a failure to prescribe rather than a failure to adhere. Testing for metabolites of disease‐modifying HF drugs in urine using HPLC‐MS is feasible and is a useful adjunct to a specialist HF service. At present, the distinction between treatment failure and failure to take treatment is not always clear, which is important because the investigation and potential solutions are different. The former needs initiation of additional therapies and consideration of additional diagnoses, whereas the latter requires strategies to understand reasons underlying poor adherence and collaborative working to improve this: the wrong strategy will be ineffective.

Impact of the COVID-19 pandemic on the management of chronic heart failure.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge. Meeting this has resulted in changes to working practices and the impact on the management of patients with heart failure with reduced ejection fraction (HFrEF) is largely unknown. We performed a retrospective, observational study contrasting patients diagnosed with HFrEF attending specialist heart failure clinics at a UK hospital, whose subsequent period of optimisation of medical therapy was during the COVID-19 pandemic, with patients diagnosed the previous year. The primary outcome was the change in equivalent dosing of ramipril and bisoprolol at 6-months. Secondary outcomes were the number and type of follow-up consultations, hospitalisation for heart failure and all-cause mortality. In total, 60 patients were diagnosed with HFrEF between 1 December 2019 and 30 April 2020, compared to 54 during the same period of the previous year. The absolute number of consultations was higher (390 vs 270; p = 0.69), driven by increases in telephone consultations, with a reduction in appointments with hospital nurse specialists. After 6-months, we observed lower equivalent dosing of ramipril (3.1 ± 3.0 mg vs 4.4 ± 0.5 mg; p = 0.035) and similar dosing of bisoprolol (4.1 ± 0.5 mg vs 4.9 ± 0.5 mg; p = 0.27), which persisted for ramipril (mean difference 1.0 mg, 95% CI 0.018-2.09; p = 0.046) and bisoprolol (mean difference 0.52 mg, 95% CI -0.23-1.28; p = 0.17) after adjustment for baseline dosing. We observed no differences in the proportion of patients who died (5.0% vs 7.4%; p = 0.59) or were hospitalised with heart failure (13.3% vs 9.3%; p = 0.49). Our study suggests the transition to telephone appointments and re-deployment of heart failure nurse specialists was associated with less successful optimisation of medical therapy, especially renin-angiotensin inhibitors, compared with usual care.

Clinical predictors of all-cause mortality in patients presenting to specialist heart failure clinic with raised NT-proBNP and no heart failure.

AimsClinical outcomes for patients suspected of having heart failure (HF) who do not meet the diagnostic criteria of any type of HF by echocardiography remain unknown. The aim of this study was to investigate the clinical predictors of all‐cause mortality in patients with suspected HF, a raised N‐terminal pro‐b‐type natriuretic peptide (NTproBNP) and who do not meet the diagnostic criteria of any type of HF by echocardiography.Methods and resultsRelevant data were taken from the Sheffield HEArt Failure (SHEAF) registry (222349P4). The inclusion criteria were presence of symptoms raising suspicion of HF, NTproBNP > 400 pg/mL, and preserved left ventricular function. Exclusion criteria were any type of HF by echocardiography. The outcome was defined as all‐cause mortality. Cox proportional‐hazards regression model was used to investigate the association between the survival time of patients and clinical variables; 1031 patients were identified with NTproBNP > 400 pg/mL but who did not have echocardiographic evidence of HF. All‐cause mortality was 21.5% (222 deaths) over the mean follow‐up (FU) period of 6 ± 2 years. NTproBNP was similar in patients who were alive or dead (P = 0.96). However, age (HR 1, P < 0.01), chronic kidney disease (CKD, HR 1.2, P < 0.01), chronic pulmonary obstructive disease (COPD, HR 1.6, P < 0.01), dementia (HR 5.9, P < 0.01), male gender (HR 1.4, P < 0.01), first‐degree atrioventricular block (HR 2.1, P < 0.01), left axis deviation (HR 1.6, P = 0.04), and diabetes (HR 1.4, P = 0.03) were associated with all‐cause mortality. In multivariate regression, age, gender, CKD stage, COPD, and dementia were independently associated with mortality. In patients with NTproBNP > 627 pg/mL, NYHA class predicted death (II, 19.6%; III, 27.4%; IV, 66.7%; P < 0.01).ConclusionsPatients with no HF on echocardiography but raised NTproBNP suffer excess mortality particularly in the presence of certain clinical variables. Age, male gender, worsening CKD stage, presence of COPD, and dementia are independently associated with all‐cause mortality in these patients. An NTproBNP > 627 pg/mL coupled with NYHA class could identify patients at greatest risk of death.

P1489An audit of 215,000 patients on primary care registers using novel electronic searches to identify patients with heart failure requiring treatment optimisation and complex device therapies

Abstract INTRODUCTION Patients with heart failure (HF) may not routinely receive review from a HF specialist and understanding of which patients may benefit from specialist therapies is not widely appreciated by non-specialists. Therefore, there may be frequent missed opportunities for patients under non-specialist care to access prognostically important therapies. PURPOSE To identify high-risk patients in primary care with HF and left ventricular systolic dysfunction (LVSD) that require optimisation and consideration for complex device therapy. METHODS 15 general practitioner (GP) practices across Cornwall were audited between between July 2018 and August 2019 with a total population of 215,114 patients. The total combined HF register in these practices was 2,925. A further 2,238 patients were identified using the case finder element of GRASP-HF, an electronic search tool, to identify patients with HF +/- LVSD not coded correctly in GP records. Electronic records were manually reviewed and selected patients, potentially benefitting from further optimisation, were electronically reviewed by a Consultant Cardiologists for final screening before being invited into a specialist HF clinic at their local GP practice. All patients received an up to date ECG prior to specialist review. Outcomes of each patient clinical review were followed-up for a minimum of 1 month. RESULTS From 5,163 patients audited, 157 underwent clinic review with a Consultant Cardiologist at their local GP practice and are described below. Patient characteristics Mean age was 75 years, 78% were male, 51% had ischaemic cardiomyopathy and 27% had AF. 66% had severe LVSD (EF &amp;lt;35%), 48% had broad QRS (&amp;gt;120ms) and only 44% were deemed to be on optimal medical therapy. Of 88 patients not fully optimised, the proportion requiring optimisation of ACEi/ARB, beta-blocker, MRA, sacubitril-valsartan and ivabradine were 57%, 30%, 36%, 7% and 1%, respectively. Patient outcomes Median follow up period was 7 months (range 2-15). 65% of all patients required further imaging of LV function to help determine onward management. 48% were potential candidates for device therapy and 3 patients (2%) were listed directly for device therapy while 5 patients (3%) declined. In total, following complete assessment, 18 patients (11%) received device implantation (12 CRT-P, 2 CRT-D, 2 ICD and 1 loop recorder) and 25 patients (16%) received sacubitril-valsartan. A change in patient clinical management was instituted in 64% of patients following specialist review. CONCLUSION This comprehensive audit of GP registers demonstrates a significant burden of patients with HF and LVSD who are not appropriately coded. This audit also identifies frequent opportunities to intensify 1st and 2nd line medical therapies and patients that may benefit from specialist therapies including complex devices. Primary care teams would benefit from regular review of their HF registers and from specialist outreach initiatives.

Infection-Related Hospitalization in Heart Failure With Reduced Ejection Fraction: A Prospective Observational Cohort Study.

Hospitalization is a common adverse event in people with heart failure and reduced ejection fraction, yet is often not primarily due to decompensated heart failure (HF). We investigated the long-term prognosis following infection-related hospitalization. We conducted a prospective observational cohort study of 711 people with heart failure and reduced ejection fraction recruited from 4 specialist HF clinics in the United Kingdom. All hospitalization episodes (n=1568) were recorded and categorized as primarily due to decompensated HF, other cardiovascular disease, infection-related, or other noncardiovascular disease. Survival was determined after the first hospitalization. During 2900 patient-years of follow-up, there were a total of 14 686 hospital days. At least one hospitalization occurred in 467 people (66%); 25% of first hospitalizations were primarily due to infection and these were not associated with typical signs including tachycardia and pyrexia. Compared with other categories of hospitalization, infection-related was associated with older age, lower serum albumin, higher blood neutrophil counts, and greater prevalence of chronic obstructive pulmonary disease at recruitment. Median survival after first infection-related hospitalization was 18.6 months, comparable to that after first decompensated HF hospitalization, even after age-sex adjustment. The burden of all-cause rehospitalization was comparable irrespective of the category of first hospitalization, but infection more commonly caused re-hospitalization after index infection hospitalization. Infection is a common driver of hospitalization in heart failure and reduced ejection fraction and often presents without classical signs. It is associated with high mortality rates, comparable to decompensated HF, and a major burden of rehospitalization caused by recurrent episodes of infection.

Structural and functional characterisation of new-onset idiopathic dilated cardiomyopathy, and its response to therapy

Introduction The prevalence of myocardial fibrosis among patients with idiopathic dilated cardiomyopathy (IDCM), as detected by the late-gadolinium cardiac magnetic resonance (LG-CMR) technique, is reported to be 28-42% in highly-selected samples from specialist heart failure clinics. The presence of fibrosis has been demonstrated to predict the incidence of major adverse cardiovascular events. However, as the heart failure duration prior to first CMR imaging in these studies was at least 12 months the prevalence of myocardial fibrosis at presentation is unknown. Moreover, the determinants of the response-to-therapy of newly diagnosed IDCM patients have not been characterised using CMR and advanced echocardiographic techniques.

Red cell distribution width: an inexpensive and powerful prognostic marker in heart failure

Red cell distribution width (RDW) is prognostic in patients with heart failure (HF), but it has not been compared with N-terminal brain natriuretic peptide (NT-proBNP). We sought to make this comparison. Patients referred to a specialist HF clinic between 2001 and 2008 were assessed comprehensively including medical history, echocardiogram, and blood tests. Cox-regression was used to assess the multivariable relationship between RDW, NT-proBNP, and all-cause mortality. A total of 1087 patients were recruited; median (IQR) follow-up was 52 months (29-66); age 72 years (64-78); 74% male; 70% ischaemic heart disease; 20% diabetic; 85% NYHA >or= 2, and 63% with at least moderate LV impairment (EF < 35% equivalent). In a multivariable model, both RDW and NT-proBNP were independently prognostic (RDW: chi(2) = 21.8 vs. 49.1 both P < 0.001). In a model using quartiles of each variable, the relative risk for each was similar for the second and third quartiles compared with the first. A larger increase in risk for NT-proBNP is seen in the fourth quartile. Red cell distribution width is a readily available test in the HF-population with similar independent prognostic power to NT-proBNP across the first to third quartiles. Prognostic models in HF should include RDW and further investigation is necessary to determine the pathological mechanism of the relationship.

Serial NT-proBNP monitoring and outcomes in outpatients with decompensation of heart failure

Background NT-proBNP is useful for heart failure (HF) diagnosis and prognosis. We examined the value of serial NT-proBNP monitoring to predict outcomes in decompensated HF patients attending a structured HF clinic. Methods Patients with decompensation of established optimally treated HF, not requiring emergency hospital admission, were enrolled in the study. Patients received intensive follow-up weekly during 4 weeks and at 3 months in specialist HF clinics. Serial NT-proBNP concentrations were measured at each visit. Primary endpoint was cardiovascular death and hospital admission for HF at 3 months. Results Fifty-nine patients were enrolled (60 ± 14 years, LVEF 27 ± 9%) and 39% had a primary endpoint during follow-up. Baseline NT-proBNP concentration (in ng/L) was 7050 ± 6620, and did not differ significantly in patients with and without events ( p = 0.22). Patients without events showed marked NT-proBNP reduction at week-1 (30% reduction), week-2 (36% reduction), week-3 (34% reduction) and week-4 (37% reduction). By contrast, patients with events showed no significant NT-proBNP reduction during follow-up. Using a general linear model, the relative NT-proBNP reductions (%) at weeks 1–4 were predictors of adverse events ( p = 0.004, p < 0.001, p = 0.001 and p = 0.03, respectively). In a stepwise multiple Cox regression analysis, NT-proBNP relative reduction (in %) at week 2 was a strong predictor of no events during follow-up (OR 0.79, 95% CI 0.70–0.88, p < 0.001). Conclusions Serial NT-proBNP monitoring in decompensated HF patients seen in a structured in-hospital HF clinic predicts cardiovascular events during follow-up. NT-proBNP may be useful in an outpatient basis to identify patients at high risk needing more aggressive therapy.

Success of a multidisciplinary heart failure clinic for initiation and up-titration of key therapeutic agents

Heart failure has a poor prognosis, yet drugs known to improve outcomes are either not prescribed, or prescribed at sub-therapeutic doses. The National Service Framework (NSF) for coronary heart disease recommended specialist heart failure clinics to address this problem but their efficacy has not been evaluated. To determine the effectiveness of a protocol-driven heart failure clinic staffed by nurse and pharmacist specialists for improving symptoms and optimising treatment with key therapeutic agents, without adversely affecting renal function. Of the 234 patients with at least one follow-up visit, 127 (57%) were receiving none or only one key therapeutic agent when first seen, this was reduced to 25 patients (11%) at most recent follow-up. The improvement in prescription rates was accompanied by significant up-titration of dose, the proportion of patients on "medium" or "high" doses rising from 43 (18%) to 134 (57%) for beta-blockers, and from 129 (55%) to 201 (86%) for ACE-inhibitors/angiotensin receptor blockers. Clinical improvement was reflected in reductions in patients with NYHA functional classes III and IV (93 (40%) to 53 (23%)), and in patients with moderate or severe symptoms. Significant reductions in alcohol consumption and cigarette smoking were recorded. Up-titration of treatment was associated with reductions in heart rate and systolic blood pressure; increases in serum potassium and creatinine concentrations were small. In a heart failure clinic staffed by nurse and pharmacist specialists, it is possible to achieve target doses of key therapeutic agents and improve symptoms without adversely affecting electrolytes or renal function.

The effect of aspirin on the ventilatory response to exercise in chronic heart failure

Patients with chronic heart failure (CHF) experience breathlessness and fatigue on exercise. One of the abnormalities seen on maximal exercise testing is an increased ventilatory response to exercise (VE/VCO(2) slope). The cause of this is unknown, but is likely to be due to a combination of interacting peripheral and central factors. Recent data have demonstrated a relation between VE/VCO(2) slope and prostaglandin levels in contracting muscles. The present study examined the influence of the presence of a potent non-selective prostaglandin inhibitor, aspirin, on the ventilatory response to exercise in a group of patients with CHF. We investigated the ventilatory response to exercise of 120 consecutive patients in sinus rhythm attending a specialist heart failure clinic. We excluded those taking clopidogrel (six patients) and those on both warfarin and aspirin or taking other non-steroidal anti-inflammatory agents (five patients). The other 109 patients were grouped according to whether they were taking aspirin (n=52 (48%)) or not (n=57 (52%)). Each patient underwent echocardiography to assess left ventricular function, and exercise testing with metabolic gas exchange to derive peak oxygen consumption (pVO(2)) and the VE/VCO(2) slope. The groups were similar in terms of age, (67 (13) vs. 66 (12) years; P=0.34) drug use, heart failure aetiology, left ventricular function (ejection fraction; 33.3 (9.4) vs. 31.8 (9.9)%; P=0.05)) and exercise tolerance (pVO(2); 20.4 (5.3) vs. 19.9 (6.0); P=0.68, and VE/VCO(2) slope; 35.4 (6.2) vs. 35.7 (9.3); P=0.73). There was no difference in the ventilatory response to exercise or the symptoms of breathlessness between the two groups. Aspirin does not appear to affect exercise performance in CHF.

Tolerability of spironolactone in patients with chronic heart failure – a cautionary message

To assess how well heart failure patients tolerate spironolactone in routine clinical practice. Retrospective analysis of 226 patients attending a specialist heart failure clinic. One hundred and thirty of 226 (57.5%) patients tried spironolactone at least once. Forty-four of 130 (33.8%) discontinued spironolactone due to side-effects after a mean of 11.1 months; 59/141 (41.8%) trials of spironolactone resulted in at least one side-effect; therapy was stopped in 30/141 (21.3%) trials due to raised potassium or creatinine. Significant risk factors for raised potassium/creatinine were age and baseline potassium level. Potentially serious side-effects are common despite appropriate use of spironolactone.