Specialized Heart Failure Clinics Research Articles

Uptake of SGLT2i and Outcomes in Patients with Diabetes and Heart Failure: A Population-Based Cohort and a Specialized Clinic Cohort

BackgroundSodium/glucose cotransporter 2 inhibitors (SGLT2i) are effective in adults with diabetes mellitus (DM) and heart failure (HF) based on randomized clinical trials. We compared SGLT2i uptake and outcomes in two cohorts: a population-based cohort of all adults with DM and HF in Alberta, Canada and a specialized heart failure clinic (HFC) cohort. MethodsThe population-based cohort was derived from linked provincial healthcare datasets. The specialized clinic cohort was created by chart review of consecutive patients prospectively enrolled in the HFC between February 2018 and August 2022. We examined the association between SGLT2i use (modeled as a time-varying covariate) and all-cause mortality or deaths/cardiovascular hospitalizations. ResultsOf the 4,885 individuals from the population-based cohort, 64.2% met the eligibility criteria of the trials proving the effectiveness of SGLT2i. Utilization of SGLT2i increased from 1.2% in 2017 to 26.4% by January 2022. In comparison, of the 530 patients followed in the HFC, SGLT2i use increased from 9.8% in 2019 to 49.1 % by March 2022. SGLT2i use in the population-based cohort was associated with fewer all-cause mortality (aHR 0.51, 95% CI 0.41–0.63) and deaths/cardiovascular hospitalizations (aHR 0.65, 95% CI 0.54–0.77). However, SGLT2i usage rates were far lower in HF patients without DM (3.5% by March 2022 in the HFC cohort). ConclusionsDespite robust randomized trial evidence of clinical benefit, the uptake of SGLT2i in patients with HF and DM remains low, even in the specialized HFC. Clinical care strategies are needed to enhance the use of SGLT2i and improve implementation.

Heart failure management model at University Medical Center Ho Chi Minh City

The program has three key components - human resources, management tools, and research training. It takes a multidisciplinary approach involving various specialists. Nurses play a central role in educating and connecting with patients. Management tools include a patient handbook for self-monitoring, a specialized heart failure clinic for post discharge follow-up, and use of standardized data variables and the REDCap platform for streamlined data collection and analysis. The program follows the EuroHeart data standards and has expanded to involve other hospitals in collaborative data collection and sharing of program experiences. Additional activities include training courses for medical staff, conferences to discuss program challenges/solutions, and a patient club to strengthen doctor-patient relationships. Standardized, multicenter management programs can optimize patient care, provide valuable real-world data to advance heart failure research in Vietnam, and continuously improve outcomes. In summary, the UMC-HCMC program exemplifies a systematic, patient-centered approach to heart failure care aiming to reduce mortality and hospitalizations. Key next steps are expanding to more sites and patient groups, and conducting further research.

Abstract 13694: Impact of an Interdisciplinary Heart Failure Clinic on Achieving Guideline-Directed Medical Therapy in the Community

Background: Guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) is underutilized despite proven benefits. Strategies to implement GDMT are needed, especially in the era of sodium-glucose cotransporter-2 inhibitors (SGLT2is). Research Question: What is the impact of embedded interdisciplinary heart failure (HF) clinics on HFrEF GDMT prescribing within community cardiology practices? Goal: Compare GDMT prescribing for HFrEF patients followed in community cardiology practices with or without the added support of embedded interdisciplinary HF clinics. Methods: This retrospective chart review of four community-based cardiology practices in North Carolina identified 2,121 patients ≥ 18 years old with a diagnosis of HFrEF (EF ≤ 40%) who had encounters from January 1 to December 31, 2022. Patients were categorized based on whether their encounters included an HF clinic provider. Patients seen in HF clinic also had access to embedded clinical pharmacists and centralized social work support. Chi square test of independence was used to assess differences between groups. Results: Significantly more patients who attended HF clinic (n=1050) compared to those receiving usual care alone (n=1071) were female (36% vs 30%, p<0.01), African American (39% vs 30%, p<0.01), and had systolic BP < 100 mmHg (12% vs 7%, p<0.01). Mean age (67.8 ± 2.4 years), rates of potassium > 5 mEq/L (10%), and rates of GFR < 30 mL/min/1.73m 2 (12%) were similar between groups. HF clinic patients had significantly higher rates of angiotensin receptor/neprilysin inhibitors (ARNis) (72% vs 46%, p<0.01), ACEi/ARB/ARNis combined (86% vs 77%, p<0.01), SGLT2is (61% vs 20%, p<0.01), and mineralocorticoid receptor antagonists (45% vs 32%, p<0.01) prescribed compared to usual care alone. HF beta blocker prescribing was similar between groups (88% vs 89%, p=NS). Conclusion: Patients receiving care in interdisciplinary HF clinics within community cardiology practices had significantly higher rates of HFrEF GDMT prescribing for 3 of the 4 drug classes. Specialized HF clinics can provide patients additional support and resources to achieve GDMT.

Abstract 13531: Uptake of SGLT2i and Outcomes in Patients With Diabetes and Chronic Heart Failure: A Community-Based Cohort and a Specialized Clinic Cohort

Introduction: Sodium/glucose cotransporter 2 inhibitors (SGLT2i) have an established benefit in people with diabetes mellitus (DM) and chronic heart failure (HF). We aimed to evaluate the uptake and impact of these agents in two cohorts: a community-based cohort of all adults with DM and HF in Alberta who had an echocardiogram and a cohort of people with DM and HF being cared for in a specialized heart failure clinic (HFC). Methods: We identified the community-based cohort using validated ICD code-based case definitions for DM and HF (physician claims, outpatient, hospitalization databases) with an echocardiogram study (available from two major centres) from 2015 (when SGLT2i were available provincially) to March 2022. In addition, we identified the HFC cohort by chart review of patients seen in the Mazankowski Alberta Heart Institute HFCconsented between February 2018 and August 2021 with HF and DM and followed them until August 2022. We examined the association between SGLT2i use and all-cause mortality and/or cardiovascular (CV)-related hospitalizations using Cox proportional hazard models adjusted for clinical covariates and time-varying SGLT2i use. Results: In 12,150 people with DM and HF in the community-based cohort, 2,321 (19.1%) were dispensed an SGLT2i compared to 208 (39.2%) of the 530 patients with DM and HF followed in the HFC. SGLT2i was associated with less CV-related hospitalization and all-cause mortality (the composite outcome) (aHR 0.65 [95%CI 0.58 - 0.73]) in the community but no difference (aHR 0.88 [95% CI 0.64 - 1.21] in the HFC. SGLT2i use was associated with less all-cause mortality (aHR 0.50 [95% CI 0.44 - 0.57]) in the community but no difference (aHR 0.81 [95% CI 0.54 - 1.20]) in the HFC. Conclusion: Despite robust randomized trial evidence of clinical benefit, the uptake of SGLT2i even in people with DM and HF remains low. Although uptake is higher in a specialized HFC overall the rate is below optimal. Multifaceted Strategies (targeted to healthcare professionals, patients, and policymakers) to guide risk identification and raise awareness on the clinical benefits of these agents are warranted.

Current status of outpatient heart failure management in Egypt and recommendations for the future.

Heart failure (HF) represents one of the greatest healthcare burdens worldwide, and Egypt is no exception. HF healthcare programmes in Egypt still require further optimization to enhance diagnosis and management of the disease. Development of specialized HF clinics (HFCs) and their incorporation in the healthcare system is expected to reduce HF hospitalization and mortality rates and improve quality of care in Egypt. We conducted a literature search on PubMed on the requirements and essential infrastructure of HFCs. Retrieved articles deemed relevant were discussed by a panel of 10 expert cardiologists from Egypt and a basic HFC model for the Egyptian settings was proposed. A multidisciplinary team managing the HFC should essentially be composed of specialized HF cardiologists and nurses, clinical pharmacists, registered nutritionists, physiotherapists, and psychologists. Other clinical specialists should be included according to patients' needs and size and structure of individual clinics. HFCs should receive patients referred from primary care settings, emergency care units, and physicians from different specialties. A basic HFC should have the following fundamental investigations available: resting electrocardiogram, basic transthoracic echocardiogram, and testing for N-terminal pro-B-type natriuretic peptide. Fundamental patients' functional assessments are assessing the New York Heart Association functional classification and quality of life and conducting the 6min walking test. guideline-directed medical therapy should be implemented, and device therapy should be utilized when available. In the first visit, once HF is diagnosed and co-morbidities assessed, guideline-directed medical therapy should be started immediately. Comprehensive patient education sessions should be delivered by HF nurses or clinical pharmacists. The follow-up visit should be scheduled during the initial visit rather than over the phone, and time from the initial visit to the first follow-up visit should be determined based on the patient's health status and needs. Home and virtual visits are only recommended in limited and emergency situations. In this paper, we provide a practical and detailed review on the essential components of HFCs and propose a preliminary model of HFCs as part of a comprehensive HF programme model in Egypt. We believe that other low-to-middle income countries could also benefit from our proposed model.

Clinical course and therapy optimization of patients after discharge from a specialized heart failure clinic.

Aim: We aimed to describe the clinical course of patients with heart failure with reduced ejection fraction (HFrEF) after discharge from the heart failure clinics (HFC). Patients & methods: We reviewed the hospital's records of 610 patients that were discharged between 2013 and 2018 from the HFC at a single centre. Patients with no recurrent contact to ambulatory cardiac care were invited to an echocardiographic assessment. Results: Of the survivors, 72% were re-referred after discharge. Nearly 30% of the patients with no recurrent contact with ambulatory cardiac care had persistent HFrEF and further therapeutical optimizations were indicated in half of them. Conclusion: This highlights the importance to identify high-risk patients that would benefit from extended management in the HFC.

Structural components for the development of a heart failure network.

Diagnosis and treatment of heart failure (HF) is challenging, and development of specialized HF networks is mandatory to warrant broad access to guideline directed therapies for patients. Numerous national cardiovascular societies recommend a three-level association of health care providers. This comprises tertiary academic centres, specialized HF clinics and specialized general cardiologists to cover the large spectrum of HF severity and entities. Although this idea of a multi-level care is widely accepted, optimal approach to build and implement a HF network service needs further definition. The core principle is that of network healthcare facilities that also consider regional peculiarities and that implements academic standards, quality indicators (QIs), interdisciplinarity and reimbursement strategies. These determinants of trans-sectoral healthcare need to be embedded in a network that provides sustainability and that incorporates QIs to objectify the efficacy of specific measures. The basis of a HF-network should be a certification system of the respective national HF association to warrant guideline standards and to prevent development of regional hierarchies or dependencies between members. This nationwide framework needs to be complemented by a federal system of regional networks, which also takes local demands into account. These regional units should incorporate digital communication and interaction pathways, structured educational programmes, certified telehealth concepts and follow-up algorithms to meet the requirements of sustainability and efficacy. We here summarize different components of HF networks and introduce the structure and development philosophy of the RUHR-HF-network that constitutes the first certified HF-clinics-network in the Ruhr area-the largest metropolitan area in Germany.

Clinical Pharmacist Led-Educational Intervention to Promote Medications' Adherence for Sudanese Patients with Heart Failure: A Prospective Study

Clinical pharmacists are in a suitable position to improve medications adherence for chronic diseases, including heart failure (HF). This study aimed to identify if the structured educational intervention by the clinical pharmacist can improve adherence to HF medications in a specialized HF clinic. Methods: A quasi-interventional study was implemented in an outpatient HF clinic for six months at Ahmed Gasim Cardiac Surgery and Renal Transplantation Center, Khartoum, Sudan. Adherence was assessed by using Morisky-4 Medication Adherence Scale (MMAS-4). Clinical pharmacist intervention using verbal and written materials composed of different aspects to promote medications adherence for HF were performed during the study period. Results: Among 110 patients, 97.3% were non-adherent to HF medications at baseline, with the exception of receiving education about HF; all sociodemographic and clinical characteristics of patients were not associated with the non-adherence status. Significant improvement in medication adherence was reported after clinical pharmacist intervention by different views of MMAS-4. There was a reduction in the total mean MMAS-4 score (2.64 ± 1.1 vs. 0.67 ± 0.9, P=0.001), and a significant increase in the percentage of patients having high adherence (2.7% vs. 56.4%, P=0.001) before and after clinical pharmacist intervention. By contrast, the proportion of patients with medium and low adherence was significantly reduced after intervention (42.7% vs. 37.3%, P=0.001) and (54.5% vs. 6.4%, P=0.001), respectively. Conclusion: Non-adherence was highly prevalent among Sudanese patients with HF; the clinical pharmacist led-educational intervention can improve medication adherence for HF medications.

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Empagliflozin in heart failure patients with reduced ejection fraction: a randomized clinical trial (Empire HF)

BackgroundData from recent cardiovascular outcome trials in patients with type 2 diabetes (T2D) suggest that sodium-glucose cotransporter 2 (SGLT2) inhibitors can prevent development of heart failure (HF) and prolong life in patients without HF. Ongoing event-driven trials are investigating whether the same effect is present in patients with well-defined HF. The mechanism behind the effect of SGLT2 inhibitors in patients with T2D and the potential effect in patients with overt HF is presently unknown.MethodsThis is a randomized, double-blinded, placebo-controlled, parallel group, clinical trial including HF patients with reduced left ventricular ejection fraction (HFrEF) with an ejection fraction ≤ 40% on optimal therapy recruited from specialized HF clinics in Denmark. The primary aim is to investigate the effect of the SGLT2 inhibitor empagliflozin on N-terminal pro-brain natriuretic peptide (NT-proBNP). Secondary endpoints include cardiac biomarkers, function and hemodynamics, metabolic and renal parameters, daily activity level, and quality of life. Patients are assigned 1:1 to 90 days treatment with empagliflozin 10 mg daily or placebo. Patients with T2D are required to be on recommended doses of anti-glycemic therapy with a hemoglobin A1c (HbA1c) of 6.5–10.0% (48–86 mmol/mol). To show a between-group difference in the change of NT-proBNP of 30%, a total of 189 patients will be included.DiscussionThe Empire HF trial will elucidate the effects and modes of action of empagliflozin in HFrEF patients with and without T2D and provide important mechanistic data which will complement ongoing event-driven trials.Trial registrationClinicaltrialsregister.eu, EudraCT Number 2017-001341-27. Registered on 29 May 2017.ClinicalTrials.gov, NCT03198585. Registered on 26 June 2017.

Yoga and breathing technique training in patients with heart failure and preserved ejection fraction: study protocol for a randomized clinical trial

BackgroundCurrent therapies for heart failure (HF) are followed by strategies to improve quality of life and exercise tolerance, besides reducing morbidity and mortality. Some HF patients present changes in the musculoskeletal system and inspiratory muscle weakness, which may be restored by inspiratory muscle training, thus increasing respiratory muscle strength and endurance, maximal oxygen uptake (VO2), functional capacity, respiratory responses to exercise, and quality of life. Yoga therapies have been shown to improve quality of life, inflammatory markers, and peak VO2 mostly in HF patients with a reduced ejection fraction. However, the effect of different yoga breathing techniques in patients showing HF with a preserved ejection fraction (HFpEF) remain to be assessed.Methods/designA PROBE (prospective randomized open blinded end-point) parallel-group trial will be conducted at two specialized HF clinics. Adult patients previously diagnosed with HFpEF will be included. After signing informed consent and performing a pre-test intervention, patients will be randomized into three groups and provided with either (1) active yoga breathing techniques; (2) passive yoga breathing techniques (pranayama); or and (3) control (standard pharmacological treatment). Follow-up will last 8 weeks (16 sessions). The post-intervention tests will be performed at the end of the intervention period for analysis of outcomes. Interventions will occur continuously according to patients’ enrollment. The main outcome is respiratory muscular resistance. A total of 33 enrolled patients are expected. The present protocol followed the SPIRIT guidelines and fulfilled the SPIRIT checklist.DiscussionThis trial is probably the first to assess the effects of a non-pharmacological intervention, namely yoga and specific breathing techniques, to improve cardiorespiratory function, autonomic system, and quality of life in patients with HFpEF.Trial registrationREBEC Identifier: RBR-64mbnx (August 19, 2012).Clinical Trials Register: NCT03028168. Registered on 16 January 2017).

Gender Differences in Utilization of Specialized Heart Failure Clinics.

Although heart failure (HF) prevalence is equally high among men and women, observed differences in the provision of care are still not fully understood. We sought to evaluate gender differences in patient profiles, diagnostic testing, medication prescription, and referrals in specialized multidisciplinary ambulatory HF clinics in Ontario. Medical chart abstraction was conducted first by randomly selecting 9 (out of 34) HF clinics in Ontario, and then by randomly selecting 100 patient records in each clinic. Data on patient demographics, comorbidities, diagnostic tests, medication use, and referrals were abstracted, covering a period from the first clinic visit up to 1 year. Descriptive statistics and regression analysis were used to assess gender differences. Of the 884 patients, only 314 were women (35.5%). At the first clinic visit, women were older, had better systolic function but worse functional status, and had a lower prevalence of hyperlipidemia, diabetes, and smoking than men. There were more women with non-ischemic HF etiology than men (63.9% vs. 43.3%, p < 0.001). Adjusted analysis did not reveal gender differences in the average number of echocardiographic assessments and in the prescription rates of evidence-based medications. Men were twice more likely to be referred to electrophysiology studies than women (18.6% vs. 7.8%, p < 0.001). The rates of dietary counseling and cardiac rehabilitation referrals were similarly low in both groups. More men than women are treated in specialized ambulatory HF clinics. Although women differ from men in selected clinical characteristics, no major differences were observed in patient management. The reasons for low enrollment rates of women into the HF ambulatory clinics need further investigation.

Effect of a diuretic adjustment algorithm and nonpharmacologic management in patients with heart failure: study protocol for a randomized controlled trial.

BackgroundOne of the challenges in treating patients with heart failure (HF) is achieving clinical stability and reducing the hospital readmission rate. A diuretic dose adjustment algorithm developed in the United States (Diuretic Treatment Algorithm, DTA) and later validated for use in Brazil (as the Algoritmo de Ajuste de Diurético, AAD) has proved feasible and readily applicable, but its effect on clinical outcomes has yet to be assessed. This report aims to describe a randomized clinical trial protocol designed to assess the effectiveness of the AAD and of nonpharmacologic management in improving clinical stability and reducing the readmission rate at 90 days in patients with HF.Methods/DesignA PROBE (prospective randomized open blinded endpoint) parallel-group design will be used. Adult patients with a diagnosis of reduced ejection fraction HF, who are being treated at a specialized HF clinic are being recruited. Those with indications for loop diuretic dose adjustment during routine clinic visits will be randomized to take part in the trial. Participants in the intervention group (IG) shall have their diuretic doses adjusted in accordance with the AAD and receive four telephone calls (one per week) over 30 days to reinforce guidance on nonpharmacological management (fluid and sodium restriction). Participants in the control group (CG) shall have their diuretic doses adjusted by a physician during the first trial visit and shall not receive any telephone calls. Patients in both groups shall return at 1 month for face-to-face reassessment. The study endpoints shall comprise readmission and/or emergency department visits due to HF decompensation within 90 days and clinical instability. All participants shall be required to have a scale at home (or easy access to one), a telephone number, agree to telephone-based follow-up, and be available to return for a 1-month trial visit. Overall, 135 patients are expected to be enrolled in each group.DiscussionThis trial shall assess the effectiveness of the AAD algorithm and non-pharmacologic management by early identification of clinical deterioration and establishment of a combined intervention to reduce emergency department visits, readmission rate, or a composite endpoint thereof.Trial registration numberClinicalTrials.gov Identifier, NCT02068937 (23 February 2014).

Effect of extended follow-up in a specialized heart failure clinic on adherence to guideline recommended therapy: NorthStar Adherence Study.

The optimal duration of a public heart failure (HF) clinic programme is unknown. This substudy of the NT-proBNP stratified follow-up in outpatient heart failure clinics (NorthStar) trial was designed to evaluate the effect of extended follow-up in an outpatient HF clinic on long-term adherence to guideline-based therapy. Patients with HF with reduced EF on optimal medical therapy (n = 921) were randomized to either extended follow-up in the HF clinic (n = 461) or discharge to primary care (n = 460) and followed for a median of 4.1 years (range: 13 months to 6.1 years). The effect of the HF clinic intervention on treatment adherence (time to at least a 90 day break in treatment) was estimated by drug dispensing from pharmacies of an ACE inhibitor/ARB, beta-blocker (BB), or mineralocorticoid receptor antagonist (MRA). Median age was 69 years, 25% were females, LVEF was 30%, and 90% were in NYHA class II-III. The HF clinic intervention did not reduce time to a 90 day break in treatment with either an ACE inhibitor/ARB [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.34-1.97, P = 0.650], a BB (HR 1.09, 95% CI 0.53-2.66, P = 0.820), or an MRA (HR 1.30, 95% CI 0.85-2.00, P = 0.238). Extended follow-up in an outpatient HF clinic did not improve long-term adherence to guideline-based therapy, and adherence did not deteriorate when follow-up was shifted from the HF clinic to primary care.

Differences in the Clinical Characteristics of Ethnic Minority Groups With Heart Failure Managed in Specialized Heart Failure Clinics

ObjectivesThe purpose of our study was to compare the clinical features of Chinese and South Asians, the 2 largest minority populations in Canada, with non-Chinese/non-South Asian (NCH/NSA) patients managed in common social macroenvironments and healthcare systems. BackgroundHeart failure is an increasingly prevalent condition. Although ethnic minorities comprise a growing proportion of the population in Western countries, the clinical profiles of ethnic minorities with heart failure are largely unknown. MethodsWe analyzed records of patients with heart failure managed in 2 specialized clinics in Ontario, Canada. Of the 1,671 patients, 181 (11%) were identified as Chinese and 215 (13%) as South Asian. ResultsOur analyses showed that fewer Chinese patients were found to have a history of myocardial infarction (MI) (30% vs. 52%), 3 occluded/stenosed coronary vessels on angiogram (47% vs. 51%), grade 3 or worse left ventricular dysfunction (22% vs. 42%), and a prescription of angiotensin-converting enzyme inhibitors (42% vs. 63%) compared with their NCH/NSA counterparts. In contrast, South Asian patients more frequently had a past history of an MI (70% vs. 52%), 3 occluded/stenosed coronary vessels on angiogram (68% vs. 51%), and treatment with coronary revascularizations (55% vs. 40%) compared with NCH/NSA patients. ConclusionsOur study demonstrates important differences in comorbid conditions, clinical characteristics, and treatment patterns among Chinese and South Asian patients compared with NCH/NSA patients with heart failure. Awareness of these differences will help to develop differential strategies necessary to prevent and manage heart failure among ethnic minority groups.

Disease management program in implementing the guidelines of heart failure

Introduction: Heart Failure (HF) is a public health problem around the world with a fast growing prevalence. Optimized treatment has proven to be effective in reducing morbidity and mortality. HF Registers have demonstrated a heterogeneity regarding the application of the Guidelines. Specialized HF clinics results in a improvement of quality of life due to better adherence to the treatment. Regarding hospitalized patients there is no evidence of the benefit of management programs. Our hypothesis is that a hospital management program has a key role in better adherence to current Guidelines. Objective: Evaluate the role of Management Program in HF treatment in hospitalized patients. Material and methods: We evaluated 418 patients with HF and ventricular dysfunction (LVEF<45%), divided in two groups: G1- 258 hospitalized patients treated in 2010, before the adoption of the program, and G2- 160 patients including 346 hospitalization, hospitalized after the implementation of the Program. The Program consist in a trained and specialized multidisciplinary team working directly with the HF patients including a telephone follow up interview after discharge. We evaluated: dosage of BNP/NT pro BNP, prescription of ACE inhibitors/BRA, beta-blockers, spironolactone, triple association of these drugs and anticoagulation for atrial fibrillation on discharge. For statistical analysis we used the Wilcoxon Rank-Sum test. Results: See Table 1. View this table: Table 1 Conclusion: The Clinical Care Management Program for patients with HF admitted in a Hospital was very efficient, with significant increase of the adherence upon the recommendations of the current Guidelines.

Long term adherence in primary care versus a specialized heart failure clinic for outpatients with systolic heart failure

Purpose: Most European countries have implemented Heart Failure (HF) clinic programs to educate the patients in self-care and optimize doses and adherence of neurohormonal blockade. The optimal duration of the HF clinic program is, however, unknown. This study was, therefore, designed to evaluate the effect of extended follow up in an outpatient HF clinic on long-term adherence to guideline based therapy. Methods: Multicenter (18 HF clinic's) randomized clinical trial. After education in self-care and optimization in guideline therapy in HF clinic systolic HF patients (N=921) were randomized to either extended follow up the HF clinic (N=461) or discharge to the primary care (N=460) and the patients were followed for a median of 2.5 years (range: 3 months-4.5 years). The effect of the HF clinic intervention on treatment adherence (time to 90 days break in treatment) estimated by drug dispensing from pharmacies with either an Angiotensin Converting Enzyme-Inhibitor/Angiotensin II Receptor Blocker (ACE-I/ARB), a Beta-Blocker (BB) or an Aldosterone Receptor Antagonist (ARA) was then evaluated in Cox Proportional Hazard Models. Subgroup analyses were performed to identify high-risk patients with particular benefit. Results: At randomization the two groups of patients were matched on baseline characteristics. Median Age was 69 years, 25% were females, LVEF was 30%, 90% were in NYHA class II-III and NT-proBNP was 801 pg/ml, 89% were treated with an ACE-I/ARB, 85% with a BB and 32% with an ARA. The HF clinic intervention did not reduce time to a 90 days break in treatment with either an ACE-I/ARB (Hazard ratio (HR): 0.82, 95%-Confidence Interval (CI): 0.34-1.97, P=0.650), a BB (HR: 1.09, 95%-CI: 0.53-2.66, P=0.820) or an ARA (HR: 1.30, 95% CI: 0.85-2.00, P=0.238). No interaction between adherence, the HF clinic intervention or any high-risk subgroup was observed (NT-proBNP > 1000 pg/ml, eGFR 0.05 for all). At follow up end adherence was 90% for ACE-I/ARB's, 88% for BB's and 75% for ARA's and did not differ between treatment arms (LogRank > 0.05 for all). Conclusions: Extended follow up in an outpatient HF clinic did not improve long-term adherence to guideline based therapy and adherence did not deteriorate when follow-up was shifted from the HF clinic to primary care. However, novel strategies to improve long term adherence for aldosterone receptor antagonists are needed.

Gender and Other Disparities in Referral to Specialized Heart Failure Clinics Following Emergency Department Visits

Persons with heart failure (HF) at high risk for adverse events should be followed by specialized HF clinics, since follow-up by specialized HF clinics improves outcomes for HF patients. The objective was to determine whether there were disparities for gender and other factors associated with referral of patients to specialized HF clinics. In this prospective cohort study, patients with a confirmed primary diagnosis of HF were recruited by nurses at 8 hospital emergency departments (ED) in Québec, Canada. They were interviewed by telephone at 6 weeks post ED discharge and subsequently at 3 months and 6 months. Pertinent clinical variables were extracted from medical charts by trained nurses. Bivariate analysis and multiple logistic regression were used to identify whether gender and other potential factors were associated with referral to the HF clinic. We enrolled 549 patients (mean age 75.5±11.0 years; 51% males). By 6 months after their ED visit for HF, 37.6% of the cohort were referred to specialized HF clinics. Men were more likely to be referred (odds ratio [OR] 2.04; 95% confidence interval [CI] 1.12, 3.74). Other factors associated with referral were younger age (OR 0.95; 95% CI 0.92, 0.98), and systolic dysfunction HF (left ventricle ejection fraction <40%) (OR 3.08; 95% CI 1.77, 5.46). There are disparities in referral with respect to gender, age, and type of HF. These disparities in referral need to be addressed.

Patient adherence to evidence‐based pharmacotherapy in systolic heart failure and the transition of follow‐up from specialized heart failure outpatient clinics to primary care

Undertreatment with evidence-based pharmacotherapy for heart failure (HF) is an important problem, and it has been suggested that specialized HF clinics (HFCs) can improve treatment initiation and correct dosing. The objective of this study was to examine long-term adherence to and dosages of evidence-based pharmacotherapy during and after participation in specialized HFCs. Initiation, dosages, and adherence were studied in patients with systolic HF attending HFCs in Denmark from 2002 to 2009. Information was obtained from an electronic patient file and research database used in the HFCs combined with prescription data from the Danish Registry of Medicinal Product Statistics. A total of 8792 patients were included in the study. The mean age was 68 years; with a mean LVEF of 30%, and 72% were males. Long-term adherence to treatment was high for the patients who initiated renin-angiotensin system (RAS) inhibitors and beta-blockers. Adherence after 1 year was 93% for RAS inhibitors, 92% for beta-blockers, and 86% for spironolactone. After 3 years, it was 90% for RAS inhibitors, 88% for beta-blockers, and 74% for spironolactone. For patients referred back to their general practitioner (GP), adherence 1 year after they left the HFC was 89% for RAS inhibitors, 89% for beta-blockers, and 72% for spironolactone. In specialized outpatient HFCs, long-term adherence to RAS inhibitors and beta-blockers is close to optimal. Importantly, adherence was maintained after patients were referred back to their GP for continued management. This is likely to provide long-term benefits for the patients.

„Therapierefraktärer“ kardiogener Schock? „Bridging-to-recovery“ mittels Implantation eines perkutanen Assistdevices

A 27-year-old man presented with acute dyspnea and a previous respiratory tract infection with progressive dyspnoea and chest pain over 2 weeks. Clinical findings revealed severe cardiac failure with development of cardiogenic shock and need for adrenergic drug therapy for circulatory support. The electrocardiogram showed a sinus tachycardia with unspecific T-wave-inversions, the echocardiogram revealed a dilated left ventricle and severely reduced systolic LV-function. An acute coronary syndrome could be excluded by coronary angiogram. A myocardial biopsy was taken to exclude giant cell myocarditis. The immediate initiation of a mechanical circulatory support by an Extracorporal Membrane Oxygenator (ECMO) facilitated rapid hemodynamic stabilization and recovery of organ function. A drug-only circulatory support very often does not enable stabilization of a patient in progressive cardiogenic shock and cannot prevent multiorgan dysfunction. Therefore implantation of an assist device facilitates a "bridging-to-recovery" or a "bridging-to transplant" concept in critically ill patients presenting with cardiogenic shock. The bridging also allows for reviewing etiology and evaluation of further treatment options. In case of recovery continuous care in a specialized Heart Failure Clinic can help to maintain the clinical status and offer frequent reevaluation of cardiac status and therapeutic concepts.