Protocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life

Risk of readmission and death after hospitalization for worsening heart failure: Role of post-discharge follow-up visits in a real-world study from the Grand Est Region of France

AIMS

Patients who experience hospitalizations due to heart failure (HF) face a significant risk of readmission and mortality. Our objective was to evaluate whether the risk of hospitalization and mortality following discharge from HF hospitalization differed based on adherence to the outpatient follow-up (FU) protocol comprising an appointment with a general practitioner (GP) within 15 days, a cardiologist within 2 months or both (termed combined FU).

METHODS AND RESULTS

We studied all adults admitted for a first HF hospitalization from 2016 to 2020 in France's Grand Est region. Association between adherence to outpatient FU and outcomes were assessed with time-dependent survival analysis model. Among 67 476 admitted patients (mean age 80.3 ± 11.3 years, 53% women), 62 156 patients (92.2%) were discharged alive and followed for 723 (317-1276) days. Combined FU within 2 months was used in 21.1% of patients, with lower rates among >85 years, women, and those with higher comorbidity levels (p < 0.0001 for all). Combined FU was associated with a lower 1-year death or rehospitalization (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.94, p < 0.0001) mostly related to lower mortality (adjusted HR 0.65, 95% CI 0.62-0.68, p < 0.0001) whereas HF readmission was higher (adjusted HR 1.19, 95% CI 1.15-1.24, p < 0.0001). When analysing components of combined FU separately, 1-year mortality was more related to cardiologist FU (HR 0.65, 95% CI 0.62-0.67, p < 0.0001), than GP FU (HR 0.87, 95% CI 0.85-0.90, p < 0.0001).

CONCLUSION

Combined FU is carried out in a minority of patients following HF hospitalization, yet it is linked to a substantial reduction in 1-year mortality, albeit at the expense of an increase in HF hospitalizations.

Remote Management of Patients with Cardiac Implantable Electronic Devices during the COVID-19 Pandemic

Remote monitoring (RM) is the newest function of cardiac implantable electronic devices (CIEDs). In our observational retrospective analysis, we aimed to assess whether telecardiology could be a safe alternative to routine outpatient examinations during the COVID-19 pandemic. The in- and outpatient visits, the number of acute cardiac decompensation episodes, the RM data from CIEDs, and general condition were examined via questionnaires (KCCQ, EQ-5D-5L). Regarding the enrolled 85 patients, the number of personal patient appearances was significantly lower in the year following the pandemic outbreak compared to the previous year (1.4 ± 1.4 and 1.9 ± 1.2, p = 0.0077). The number of acute decompensation events was five before and seven during lockdown (p = 0.6). Based on the RM data, there was no significant difference in heart failure (HF) markers (all related p > 0.05); only patient activity increased after restrictions were lifted compared to that before the lockdown (p = 0.03). During restrictions, patients reported increased anxiety and depression compared to their previous state (p < 0.001). There was no subjective change in the perception of HF symptoms (p = 0.7). Based on the subjective perception and CIED data, the quality of life of patients with CIED did not deteriorate during the pandemic, but their anxiety and depression intensified. Telecardiology may be a safe alternative to routine inpatient examination.

Effectiveness and Safety of Sacubitril/Valsartan in Patients with Chronic Kidney Disease-A Real-World Experience

BACKGROUND

data regarding the effectiveness and safety of sacubitril/valsartan in heart failure and reduced ejection fraction (HFrEF) patients with chronic kidney disease (CKD) are scarse.

OBJECTIVE

to evaluate the effectiveness and safety of sacubitril/valsartan in HFrEF and CKD in a real-world population.

METHODS

we included consecutive ambulatory HFrEF patients that initiated sacubitril/valsartan between February 2017 and October 2020, stratified by CKD (KDIGO stage 5 excluded).

PRIMARY OUTCOMES

the incidence rate per 100 patient-years and the annualized length of stay (LOS) of acute decompensated HF hospitalizations (HFH).

SECONDARY OUTCOMES

all-cause mortality, NYHA improvement, and titration of sacubitril/valsartan.

RESULTS

We included 179 patients, 77 with CKD, those being older (72 ± 10 vs. 65 ± 12 years, p < 0.001), had higher NT-proBNP (4623 ± 5266 vs. 1901 ± 1835 pg/mL, p < 0.001), and high anaemia incidence (p < 0.001). After 19 ± 11 months, a significant reduction in HFH adjusted incidence rate (57.5% decrease in CKD vs. 74.6%, p = 0.261) was observed, with 5 days there was a reduction in annualized LOS in both groups (p = 0.319). NYHA improved similarly in both groups (p = 0.670). CKD patients presented non-significant higher all-cause mortality (HR = 2.405, 95%CI: [0.841; 6.879], p = 0.102). Both groups had similar sacubitril/valsartan maximum dose achievement and drug withdrawal.

CONCLUSION

sacubitril/valsartan was effective on reducing HFH and LOS without affecting all-cause mortality in a CKD real-world population.

Early emergency readmission frequency as an indicator of short-, medium- and long-term mortality post-discharge from hospital

Frequent emergency readmissions, an indicator of quality of care, has been rising in England but the underlying reasons remain unclear. We examined the association of early readmissions with subsequent mortality in adults, taking into account the underlying presenting diagnoses and hospital length of stay (LOS). Data of alive-discharge episodes were prospectively collected between 01/04/2017 and 31/03/2019 in an National Health Service hospital, comprising 32,270 patients (46.1% men) aged 18-107 years (mean = 64.0, ± SD = 20.5 years). The associations of readmission frequency within 28 days of discharge and mortality within 30 days and 6 months of hospital discharge, and over a 2-year period were evaluated, adjusted for presenting diagnoses, LOS, age and sex during the first admission. Analysis of all patients 18-107 years (reference: no readmission) showed mortality within 30 days was increased for 1 readmission: event rate = 9.2%, odds ratio (OR) = 3.4 (95% confidence interval (CI) = 2.9-4.0), and ≥ 2 readmissions: event rate = 10.0%, OR = 2.6 (95%CI = 2.0-3.3), and within 6 months for 1 readmission: event rate = 19.6%, OR = 3.0 (95%CI = 2.7-3.4), and ≥ 2 readmissions: event rate = 27.4%, OR = 3.4 (95%CI = 2.9-4.0), and over a 2-year period for 1 readmission: event rate = 25.5%, hazard ratio = 2.2 (95%CI = 2.0-2.4), and ≥ 2 readmissions: event rate = 36.1%, hazard ratio = 2.5 (95%CI = 2.2-2.8). Within the age groups 18-49, 50-59, 60-69, 70-79 and ≥ 80 years, readmissions were also associated with increased risk of mortality within 3 months and 6 months of discharge, and over 2-year period. In conclusion, early hospital readmission predicts short-, medium- and long-term mortality post-discharge from hospital in adults aged 18-107 years, independent of underlying presenting conditions, LOS, age and sex. Further research focussing on safe discharge and follow-up patient care may help reduce preventable readmissions and post-discharge mortality.

Heart and brain interactions in heart failure: Cognition, depression, anxiety, and related outcomes

BACKGROUND

Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood.

OBJECTIVES

To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact.

METHODS

Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6^th and 12^th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death.

RESULTS

43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score <22 at discharge conferred a sixfold greater risk of HF readmission [HR=6.42 (1.26-32.61); p=0.025], also predicting all-cause readmissions [HR=4.00 (1.15-13.95); p=0.03] and death or all-cause readmissions [HR=4.63 (1.37-15.67); p=0.014]. Patients with higher MoCA score showed a greater ability to deal with their disease (p=0.038). At discharge, 14% and 18.6% had an abnormal HADS score for depression and anxiety, respectively, which remained stable during follow-up and was not related to MoCA.

CONCLUSIONS

Cognitive function, anxiety and depressive status remain stable in HF patients despite optimized HF therapy. Cognitive status shall be routinely screened to adopt attitudes that improve management as it has an impact on HF-related QoL and prognosis.

Frequent identical admission-readmission episodes are associated with increased mortality

Frequent emergency readmissions may associate with health consequences. We examined the association between readmissions within 28 days of hospital discharge and mortality in 32,270 alive-discharge episodes (18-107 years). Data collected between 1 April 2017 and 31 March 2019 are presented as age- and sex-adjusted hazard ratios (HR) with 95% confidence interval (CI).Compared with no readmission, mortality risk over a 2-year period was increased with one non-identical admission-readmission (AR) episode: HR = 2.4 (2.2-2.7), two or more non-identical AR episodes: HR = 3.0 (2.7-3.4), one identical AR episode: HR = 4.7 (3.6-6.1) and two or more identical AR episodes: HR = 5.0 (3.8-6.7). Eight conditions associated with AR episodes had increased risk of mortality including congestive heart failure: HR = 2.7 (2.2-3.2), chronic pulmonary obstructive disease: HR = 3.0 (2.5-3.6), pneumonia: HR = 2.0 (1.8-2.3), sepsis: HR = 2.2 (1.9-2.5), endocrine disorders: HR = 1.9 (1.6-2.3), urinary tract infection: HR = 1.5 (1.3-1.7), psychiatric disorders: HR = 1.5 (1.1-2.1) and haematological disorders: HR = 1.5 (1.2-1.9). Frequent identical AR episodes, particularly from chronic and age-related conditions, are associated with increased mortality.

Non-invasive telemonitoring improves outcomes in heart failure with reduced ejection fraction: a study in high-risk patients

AIMS

Non-invasive telemonitoring (TM) in patients with heart failure (HF) and reduced left ventricular ejection fraction (HFrEF) may be useful in the early diagnosis of HF decompensation, allowing therapeutic optimization and avoiding re-hospitalization. We describe a TM programme in this population and evaluate its effectiveness during a 12 month period.

METHODS AND RESULTS

We conducted a single-centre study of patients discharged from hospital after decompensated HF, allocated into three groups: prospective TM programme, prospective HF protocol follow-up programme (PFP) with no TM facilities, and retrospective propensity-matched usual care (UC). TM effectiveness was assessed by all-cause hospitalizations and mortality; HF-related hospitalization (HFH), days lost to unplanned hospital admissions/death, functional capacity and quality of life (New York Heart Association, Kansas City Cardiomyopathy Questionnaire, 6 min walk test, and plasma N-terminal pro-brain natriuretic peptide) were also evaluated. A total of 125 patients were included [65.9 ± 11.9 years, 32% female, left ventricular ejection fraction 27% (21-32)]. TM was similar to PFP regarding effectiveness; TM reduced all-cause hospitalization and mortality (HR 0.27; 95% CI 0.11-0.71; P < 0.01) and HFH (HR 0.29; 95% CI 0.10-0.89; P < 0.05) as compared with UC. TM reduced the average number of days lost due to unplanned hospital admissions or all-cause death as compared with PFP (5.6 vs. 12.4 days, P < 0.05) and UC (5.6 vs. 48.8 days, P < 0.01). Impact on quality of life was similar between TM and PFP (P = 0.36).

CONCLUSIONS

In patients with HFrEF and recent HF hospitalization, non-invasive TM reduced 12 month all-cause hospitalization/mortality and HFH as compared with usual care. TM also reduced the number of days lost due to unplanned hospital admission/death as compared with either an optimized protocol-based follow-up programme or usual care.