Nurse-Led Heart Failure Clinics Are Associated With Reduced Mortality but Not Heart Failure Hospitalization

Effectiveness of nurse-led heart failure clinic: A systematic review

Objectives

Heart failure is a stage of various cardiovascular diseases and constitutes a growing major public health problem worldwide. Nurse-led heart failure clinics play an important role in managing heart failure. All nurse-led heart failure clinic services are clinic-based. We conducted a systematic review to describe the contents and impact of nurse-led heart failure clinics.

Methods

A review of nurse-led heart failure clinic research was undertaken in PubMed, Embase, Web of Science, and Cochrane Library. The search was initially conducted on October 23, 2022 and updated on November 21, 2023. Articles were appraised using the Joanna Briggs Institute Appraisal criteria by two independent reviewers. This review was registered on PROSPERO (CRD42022352209).

Results

Twelve articles were included in this systematic review. The nurse-led heart failure clinic contents were: medication uptitration, educational counselling, evidence-based transitional care, psychosocial support, physical examination and mental well-being assessment, therapy monitoring and adjustment, follow-up, and phone consultations. Most studies reported largely positive clinical outcomes in nurse-led heart failure clinics. Four studies examined the quality of life and reported conflicting results; four studies examined medication titration efficacy, and the results were generally positive. Only two studies examined cost-effectiveness.

Conclusions

Nurse-led heart failure clinics have shown a largely positive impact on patient outcomes, quality of life, and medication titration efficacy. More randomised controlled trials and other studies are needed to obtain more robust conclusions.

Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice

AIMS

Recent guidelines recommend four core drug classes (renin-angiotensin system inhibitor/angiotensin receptor-neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium-glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation.

METHODS AND RESULTS

A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1-2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%).

CONCLUSIONS

Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.

How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC

Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.

The management of heart failure in Sweden-the physician's perspective: a survey

Aims

To assess the barriers to guideline-directed medical therapy (GDMT) use in heart failure (HF), diagnostic workup and general knowledge about HF among physicians in Sweden.

Methods

A survey about the management of HF was sent to 828 Swedish physicians including general practitioners (GPs) and specialists during 2021-2022. Answers were reported as percentages and comparisons were made by specialty (GPs vs. specialists).

Results

One hundred sixty-eight physicians participated in the survey (40% females, median age 43 years; 41% GPs and 59% specialists). Electrocardiography and New York Heart Association class evaluations are mostly performed once a year by GPs (46%) and at every outpatient visit by specialists (40%). Echocardiography is mostly requested if there is clinical deterioration (60%). One-third of participants screen for iron deficiency only if there is anemia. Major obstacles to implementation of different drug classes in HF with reduced ejection fraction are related to side effects, with no significant differences between specialties. Device implantation is deemed appropriate regardless of aetiology (69%) and patient age (86%). Specialists answered correctly to knowledge questions more often than GPs. Eighty-six percent of participants think that GDMT should be implemented as much as possible. Most participants (57%) believe that regular patient assessment in nurse-led HF clinics improve adherence to GDMT.

Conclusion

Obstacles to GDMT implementation according to physicians in Sweden mainly relate to potential side effects, lack of specialist knowledge and organizational aspects. Further efforts should be placed in educational activities and structuring of nurse-led clinics.

Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

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.

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 6 min 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.

Association between a hospitalization for heart failure and the initiation/discontinuation of guideline-recommended treatments: An analysis from the Swedish Heart Failure Registry

AIMS

To investigate whether a heart failure (HF) hospitalization is associated with initiation/discontinuation of guideline-directed medical HF therapy (GDMT) and consequent outcomes.

METHODS AND RESULTS

Among patients in the Swedish HF registry with an ejection fraction <50% enrolled in 2009-2018, initiation/discontinuation of GDMT was investigated by assessing dispensations of GDMT in those with versus without a HF hospitalization. Of 14 737 patients, 6893 (47%) were enrolled when hospitalized for HF. Initiation of GDMT was more likely than discontinuation following a HF hospitalization compared to a control group of patients without a HF hospitalization (odds ratio range 2.1-4.0 vs. 1.4-1.6 for the individual medications), although the proportion of patients not on GDMT was still high (8.1-44.0%). Key patient characteristics triggering less use of GDMT (i.e. less initiation or more discontinuation) were older age and worse renal function. Following a HF hospitalization, initiation of renin-angiotensin system inhibitors/angiotensin receptor-neprilysin inhibitors or beta-blockers was associated with lower and their discontinuation with higher mortality risk, but no association with mortality was observed for initiation/discontinuation of mineralocorticoid receptor antagonists.

CONCLUSIONS

Following a HF hospitalization, initiation of GDMT was more likely than discontinuation, although still limited. Perceived or actual low tolerance were barriers to GDMT implementation. Early re-/initiation of GDMT was associated with better survival. Our findings represent a call for further implementing the current guideline recommendation for an early re-/initiation of GDMT following a HF hospitalization.

A multicomponent complex intervention for supportive follow-up of persons with chronic heart failure: a randomized controlled pilot study (the UTILE project)

BACKGROUND

Heart failure (HF) is a progressive disease associated with a high burden of symptoms, high morbidity and mortality, and low quality of life (QoL). This study aimed to evaluate the feasibility and potential outcomes of a novel multicomponent complex intervention, to inform a future full-scale randomized controlled trial (RCT) in Switzerland.

METHODS

We conducted a pilot RCT at a secondary care hospital for people with HF hospitalized due to decompensated HF or with a history of HF decompensation over the past 6 months. We randomized 1:1; usual care for the control (CG) and intervention group (IG) who received the intervention as well as usual care. Feasibility measures included patient recruitment rate, study nurse time, study attrition, the number and duration of consultations, intervention acceptability and intervention fidelity. Patient-reported outcomes included HF-specific self-care and HF-related health status (KCCQ-12) at 3 months follow-up. Clinical outcomes were all-cause mortality, hospitalization and days spent in hospital.

RESULTS

We recruited 60 persons with HF (age mean = 75.7 years, ± 8.9) over a 62-week period, requiring 1011 h of study nurse time. Recruitment rate was 46.15%; study attrition rate was 31.7%. Follow-up included 2.14 (mean, ± 0.97) visits per patient lasting a total of 166.96 min (mean, ± 72.55), and 3.1 (mean, ± 1.7) additional telephone contacts. Intervention acceptability was high. Mean intervention fidelity was 0.71. We found a 20-point difference in mean self-care management change from baseline to 3 months in favour of the IG (Cohens' d = 0.59). Small effect sizes for KCCQ-12 variables; less IG participants worsened in health status compared to CG participants. Five deaths occurred (IG = 3, CG = 2). There were 13 (IG) and 18 (CG) all-cause hospital admissions; participants spent 8.90 (median, IQR = 9.70, IG) and 15.38 (median, IQR = 18.41, CG) days in hospital. A subsequent full-scale effectiveness trial would require 304 (for a mono-centric trial) and 751 participants (for a ten-centre trial) for HF-related QoL (effect size = 0.3; power = 0.80, alpha = 0.05).

CONCLUSION

We found the intervention, research methods and outcomes were feasible and acceptable. We propose increasing intervention fidelity strategies for a full-scale trial.

TRIAL REGISTRATION

ISRCTN10151805 , retrospectively registered 04/10/2019.

Use of and association between heart failure pharmacological treatments and outcomes in obese versus non-obese patients with heart failure with reduced ejection fraction: data from the Swedish Heart Failure Registry

AIMS

To investigate the use of guideline-directed medical therapies (GDMT) and associated outcomes in obese (body mass index ≥30 kg/m2 ) versus non-obese patients with heart failure (HF) with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Patients with HFrEF from the Swedish HF Registry were included. Of 16 116 patients, 24% were obese. In obese versus non-obese patients, use of treatments was 91% versus 86% for renin-angiotensin system inhibitors (RASi)/angiotensin receptor-neprilysin inhibitors (ARNi), 94% versus 91% for beta-blockers, 53% versus 43% for mineralocorticoid receptor antagonists. Obesity was shown to be independently associated with more likely use of each treatment, triple combination therapy, and the achievement of target dose by multivariable logistic regressions. Multivariable Cox regressions showed use of RASi/ARNi and beta-blockers being independently associated with lower risk of all-cause/cardiovascular death regardless of obesity, although, when considering competing risks, a lower risk of cardiovascular death with RASi/ARNi in obese versus non-obese patients was observed. RASi/ARNi were associated with lower risk of HF hospitalization in obese but not in non-obese patients, whereas beta-blockers were not associated with the risk of HF hospitalization regardless of obesity. At the competing risk analysis, RASi/ARNi use was associated with higher risk of HF hospitalization regardless of obesity.

CONCLUSION

Obese patients were more likely to receive optimal treatments after adjustment for factors affecting tolerability, suggesting that perceived beyond actual tolerance issues limit GDMT implementation. RASi/ARNi and beta-blockers were associated with lower mortality regardless of obesity, with a greater association between RASi/ARNi and lower cardiovascular death in obese versus non-obese patients when considering competing risk.

Nutrition nurse-led outpatient 'hot' clinics are efficient and cost-effective: a retrospective single-centre evaluation

BACKGROUND

Nutrition nurses work in multidisciplinary and nurse-led outpatient clinics. The daily nutrition nurse-led 'hot' clinic in this study sees patients for enteral or home parenteral nutritional support. Appointments may be for routine procedures or emergency reviews.

AIMS

This study aimed to identify activities and procedures performed in the nutrition nurse-led clinic, identifying admission avoidance activity.

METHODS

Nurse-held records for the period from April 2018 to March 2020 were reviewed retrospectively. Data were collated in an Excel spreadsheet for analysis and results are presented using descriptive statistics.

RESULTS

Records covered a total of 590 patients, 294 men and 296 women with a median age of 59 years, and 606 procedures. Key activities were troubleshooting enteral feeding tubes (29%), insertion of fine-bore nasogastric feeding tubes (18%) and management of home parenteral nutrition issues (11%). The presenting problem or issue was resolved in 90% of patients, with no need for hospital admission or additional medical review.

CONCLUSION

The nutrition nurse-led clinic provides an efficient and cost-effective service, preventing hospital admission and emergency department attendance in most cases.

Introduction of specialized heart failure nurses in primary care and its impact on readmissions

BACKGROUND

Heart failure (HF) has a 2% prevalence in the population and is a major cause of morbidity and mortality. Multiple efforts have been made worldwide to improve quality of care and decrease unplanned readmissions for HF patients, one of which has been the introduction of specialist HF nurses (HFN) in primary health care. The present evidence on the benefits of HFN is contradicting. This study aims to evaluate the impact of a quality improvement intervention, availability of a HFN in Swedish primary care, on hospital readmissions.

METHODS

All patients over the age of 65 with a HF diagnosis and with complete information on availability of a HFN were included in this retrospective register-based study. Using propensity score matching (PSM) techniques, two comparable groups of 128 patients each were created according to the exposure status, availability or no availability of a HFN. The rate of readmission was compared between the groups.

RESULTS

Using PSM, 256 patients were matched, 128 in the HFN group and 128 in the no-HFN group. A total of 50% and 46.09% of patients in the HFN and no-HFN groups were readmitted, respectively. Mean number of readmissions per patient was 1.19 (SD 0.61) in the HFN group and 1.10 (SD 0.44) in the no-HFN group. Patients in the HFN had 17.6% higher odds of being readmitted during the study period, OR: 1.176 (CI: 0.716-1.932), and 3.8% lower odds of being readmitted within 30 days, OR: 0.962 (CI: 0.528-1.750).

CONCLUSIONS

Availability of a HFN in primary care was not significantly associated with reduced readmissions for the patients included in this study. Further investigations are warranted looking at the impacts of availability and access to a HFN in primary care on readmissions and other patient outcomes.

Trajectories in New York Heart Association functional class in heart failure across the ejection fraction spectrum: data from the Swedish Heart Failure Registry

AIMS

To investigate incidence, predictors and prognostic implications of longitudinal New York Heart Association (NYHA) class changes (i.e. improving or worsening vs. stable NYHA class) in heart failure (HF) across the ejection fraction (EF) spectrum.

METHODS AND RESULTS

From the Swedish HF Registry, 13 535 patients with EF and ≥2 NYHA class assessments were considered. Multivariable multinomial regressions were fitted to identify the independent predictors of NYHA change. Over a 1-year follow-up, 69% of patients had stable, 17% improved, and 14% worsened NYHA class. Follow-up in specialty care predicted improving NYHA class, whereas an in-hospital patient registration, lower EF, renal disease, lower mean arterial pressure, older age, and longer HF duration predicted worsening. The association between NYHA change and subsequent outcomes was assessed with multivariable Cox models. When adjusting for the NYHA class at baseline, improving NYHA class was independently associated with lower while worsening with higher risk of all-cause and cardiovascular mortality, and first HF hospitalization. After adjustment for the NYHA class at follow-up, NYHA class change did not predict morbidity/mortality. NYHA class assessment at baseline and follow-up predicted morbidity/mortality on top of the changes. Results were consistent across the EF spectrum.

CONCLUSION

In a large real-world HF population, NYHA class trajectories predicted morbidity/mortality after extensive adjustments. However, the prognostic role was entirely explained by the resulting NYHA class, i.e. the follow-up value. Our results highlight that considering one-time NYHA class assessment, rather than trajectories, might be the preferable approach in clinical practice and for clinical trial design.

Validation of the ELAN-HF Score and self-care behaviour on the nurse-led heart failure clinic after admission for heart failure

AIM

To validate the predictive value of the European coLlaboration on Acute decompeNsated Heart Failure (ELAN-HF) score, and to assess the effect of self-care behaviour on readmission and mortality in patients after admission with acute decompensated heart failure (ADHF).

DESIGN

Quantitative, prospective, single centre, cohort study.

METHODS

N-Terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured on admission and discharge, and were used together with clinical and laboratory parameters to calculate the ELAN-HF score. Patients were stratified into four risk groups (low, intermediate, high, very high) according to their ELAN-HF score. The performance of the ELAN-HF score was evaluated and compared to the original study. Self-care behaviour was assessed by the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Survival analysis was used to estimate the association between both scores and re-admission for HF and/or all-cause mortality within 180 days.

RESULTS

88 patients were included. The median age of the study population was 75 years (IQR 69-83), 43% was female. NYHA III/IV functional class was present at discharge in 68 patients (85%) and 27 patients (34%) had a left ventricular ejection fraction < 40%. Complete data and 180 day follow up was available for 80 patients. 55% reached the endpoint of readmission and/or all-cause mortality. There was a significant association between the ELAN-HF score and re-admission and/or mortality < 180 days (HR = 1.25, 95% CI 1.08-1.45, p = 0.003). The median EHFScBS-9 score was 68.1 (IQR 58.3 - 77.8). There was no significant association between the EHFScBS-9 score and readmission and/or mortality < 180 days (HR = 1.01, 95% CI 0.99-1.03, p = 0.174).

CONCLUSION

This study confirms the validity and therefore the potential of the ELAN-HF score to triage patients with ADHF before discharge. Using this score may optimize the follow-up treatment on the nurse-led heart failure clinic in order to decrease readmission and mortality. Self-care behaviour was non-significantly associated with readmission and/or mortality in our study population.

TRIAL REGISTRATION

This study has been registered with the ethics committee MEC-U (Nieuwegein, The Netherlands), registration nr: V.160999/W18.208/HG/mk.

Evidence-based Therapy in Older Patients with Heart Failure with Reduced Ejection Fraction

Older patients are becoming prevalent among people with heart failure (HF) as the overall population ages. However, older patients are largely under-represented, or even excluded, from randomised controlled trials on HF with reduced ejection fraction, limiting the generalisability of trial results in the real world and leading to weaker evidence supporting the use and titration of guideline-directed medical therapy (GDMT) in older patients with HF with reduced ejection fraction. This, in combination with other factors limiting the application of guideline recommendations, including a fear of poor tolerability or adverse effects, the heavy burden of comorbidities and the need for multiple therapies, classically leads to lower adherence to GDMT in older patients. Although there are no data supporting the under-use and under-dosing of HF medications in older patients, large registry-based studies have confirmed age as one of the major obstacles to treatment optimisation. In this review, the authors provide an overview of the contemporary state of implementation of GDMT in older groups and the reasons for the lower use of treatments, and discuss some measures that may help improve adherence to evidence-based recommendations in older age groups.

Meaningful use of a digital platform and structured telephone support to facilitate remote person-centred care - a mixed-method study on patient perspectives

Background

Process evaluations are useful in clarifying results obtained from randomised controlled trials (RCTs). Traditionally, the degree of intervention usage in process evaluations is monitored by measuring dose or evaluating implementation fidelity. From a person-centred perspective, such evaluations should be supplemented with patients’ experiences of meaningful use, given that intervention use should be agreed upon between interested parties and tailored to each patient. This study aimed to elucidate patients’ experiences of a remote person-centred care (PCC) intervention by deepening the understanding of, if, how and for whom the intervention contributed to meaningful use.

Methods

Patients (n = 86) were recruited from the RCT PROTECT intervention group. A convergent mixed-method approach was implemented. Data were collected in parallel with the ongoing RCT via a survey, including ratings and written comments on meaningful or non-meaningful use. Also, interviews were performed with twelve purposefully selected participants. Descriptive statistics, logistic regression and content analysis were employed. Data sources were integrated in the results.

Results

Most participants rated the overall intervention as meaningful to use, with the telephone support rated as most meaningful. Interviews and written comments showed that patient ratings on meaningful use were explained by four categories: Not in need, Communication deficiency, Benefits in everyday life and A personal boost. Meaningful use of rating symptoms on the digital platform was predicted by living alone (adjusted odds ratio [aOR] = 2.8 P = .044). A diagnosis of chronic obstructive pulmonary disease (COPD) predicted meaningful use of digital platform direct messaging (aOR = 3.5, P = .045). Moreover, having access to direct-dial telephone contact explained meaningful use among participants with low ratings of technical competence (aOR = 3.6, P = .014).

Conclusions

The combined digital platform and structured telephone support could be helpful in identifying preventive actions to maintain health for people diagnosed with COPD and chronic heart failure but tends to be more meaningful for those diagnosed with COPD. Overall, lower adoption of the digital platform was seen compared to telephone support. Shortcomings were noted in the digital platform’s implementation that negatively influences experiences of meaningful use. When used, the intervention proved to be an easily applicable and valued tool to support preventive actions in a person-centred manner.

Evidence-Based Process Performance Measures and Clinical Outcomes in Patients With Incident Heart Failure With Reduced Ejection Fraction: A Danish Nationwide Cohort Study

BACKGROUND

Data on the association between quality of heart failure (HF) care and outcomes among patients with incident HF are sparse. We examined the association between process performance measures and clinical outcomes in patients with incident HF with reduced ejection fraction.

METHODS

Patients with incident HF with reduced ejection fraction (n=10 966) between January 2008 and October 2015 were identified from the Danish HF Registry. Data from public registries were linked. Multivariable regression analyses were used to assess the association between 6 guideline-recommended HF care processes (New York Heart Association assessment, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists, exercise training, and patient education) and all-cause and HF readmission, all-cause and HF hospital days, and mortality within 3 to 12 months after HF diagnosis. The associations were analyzed according to the percentages of all relevant performance measures fulfilled for the individual patient (0%-50% [reference group], >50%-75%, and >75%-100%) and for the individual performance measures.

RESULTS

Fulfilling >75% to 100% of the performance measures (n=5341 [48.7%]) was associated with lower risk of all-cause readmission (adjusted hazard ratio, 0.78 [95% CI, 0.68-0.89]) and HF readmission (adjusted hazard ratio, 0.71 [95% CI, 0.54-0.92]), lower use of all-cause hospital days (adjusted mean ratio, 0.73 [95% CI, 0.70-0.76]) and HF hospital days (adjusted mean ratio, 0.79 [95% CI, 0.70-0.89]), and lower mortality (adjusted hazard ratio, 0.42 [95% CI, 0.32-0.53]). A dose-response relationship was observed between fulfilling more performance measures and mortality (adjusted hazard ratio, 0.62 [95% CI, 0.49-0.77] fulfilling >50%-75% of the measures). Fulfilling individual performance measures, except mineralocorticoid receptor antagonist therapy, was associated with lower adjusted all-cause readmission, lower adjusted use of all-cause and HF hospital days, and lower adjusted mortality.

CONCLUSIONS

Fulfilling more process performance measures was associated with better clinical outcomes in patients with incident HF with reduced ejection fraction.

Patient profile and outcomes associated with follow-up in specialty vs. primary care in heart failure

AIMS

Factors influencing follow-up referral decisions and their prognostic implications are poorly investigated in patients with heart failure (HF) with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fraction (EF). We assessed (i) the proportion of, (ii) independent predictors of, and (iii) outcomes associated with follow-up in specialty vs. primary care across the EF spectrum.

METHODS AND RESULTS

We analysed 75 518 patients from the large and nationwide Swedish HF registry between 2000-2018. Multivariable logistic regression models were fitted to identify the independent predictors of planned follow-up in specialty vs. primary care, and multivariable Cox models to assess the association between follow-up type and outcomes. In this nationwide registry, 48 115 (64%) patients were planned for follow-up in specialty and 27 403 (36%) in primary care. The median age was 76 [interquartile range (IQR) 67-83] years and 27 546 (36.5%) patients were female. Key independent predictors of planned follow-up in specialty care included optimized HF care, that is follow-up in a nurse-led HF clinic [odds ratio (OR) 4.60, 95% confidence interval (95% CI) 4.41-4.79], use of HF devices (OR 3.99, 95% CI 3.62-4.40), beta-blockers (OR 1.39, 95% CI 1.32-1.47), renin-angiotensin system/angiotensin-receptor-neprilysin inhibitors (OR 1.21, 95% CI 1.15-1.27), and mineralocorticoid receptor antagonists (OR 1.31, 95% CI 1.26-1.37); and more severe HF, that is higher NT-proBNP (OR 1.13, 95% CI 1.06-1.20) and NYHA class (OR 1.13, 95% CI 1.08-1.19). Factors associated with lower likelihood of follow-up in specialty care included older age (OR 0.29, 95% CI 0.28-0.30), female sex (OR 0.89, 95% CI 0.86-0.93), lower income (OR 0.79, 95% CI 0.76-0.82) and educational level (OR 0.77, 95% CI 0.73-0.81), higher EF [HFmrEF (OR 0.65, 95% CI 0.62-0.68) and HFpEF (OR 0.56, 95% CI 0.53-0.58) vs. HFrEF], and higher comorbidity burden, such as presence of kidney disease (OR 0.91, 95% CI 0.87-0.95), atrial fibrillation (OR 0.85, 95% CI 0.81-0.89), and diabetes mellitus (OR 0.92, 95% CI 0.88-0.96). A planned follow-up in specialty care was independently associated with lower risk of all-cause [hazard ratio (HR) 0.78, 95% CI 0.76-0.80] and cardiovascular death (HR 0.76, 95% CI 0.73-0.78) across the EF spectrum, but not of HF hospitalization (HR 1.06, 95% CI 1.03-1.10).

CONCLUSIONS

In a large nationwide HF population, referral to specialty care was linked with male sex, younger age, lower EF, lower comorbidity burden, better socioeconomic environment and optimized HF care, and associated with better survival across the EF spectrum. Our findings highlight the need for greater and more equal access to HF specialty care and improved quality of primary care.

Self-care Management Intervention in Heart Failure (SMART-HF): A Multicenter Randomized Controlled Trial

BACKGROUND

Self-care behavior is important in avoiding hospitalization for patients with heart failure (HF) and refers to those activities performed with the intention of improving or restoring health and well-being, as well as treating or preventing disease. The purpose was to study the effects of a home-based mobile device on self-care behavior and hospitalizations in a representative HF-population.

METHODS AND RESULTS

SMART-HF is a randomized controlled multicenter clinical trial, where patients were randomized 1:1 to receive standard care (control group [CG]) or intervention with a home-based tool designed to enhance self-care behavior (intervention group [IG]) and followed for 240 days. The tool educates the patient about HF, monitors objective and subjective symptoms and adjusts loop diuretics. The primary outcome is self-care as measured by the European Heart Failure Self-care behavior scale and the secondary outcome is HF related in-hospital days.A total of 124 patients were recruited and 118 were included in the analyses (CG: n = 60, IG: n = 58). The mean age was 79 years, 39% were female, and 45% had an ejection fraction of less than 40%. Self-care was significantly improved in the IG compared to the CG (median (interquartile range) (21.5 [13.25; 28] vs 26 [18; 29.75], p = 0.014). Patients in the IG spent significantly less time in the hospital admitted for HF (2.2 days less, relative risk 0.48, 95% confidence interval 0.32-0.74, P = .001).

CONCLUSIONS

The device significantly improved self-care behavior and reduced in-hospital days in a relevant HF population.

Non-cardiology vs. cardiology care of patients with heart failure and reduced ejection fraction is associated with lower use of guideline-based care and higher mortality: Observations from The Swedish Heart Failure Registry

BACKGROUND

Patients with heart failure (HF) are often cared for by non-cardiologists. The implications are unknown.

METHODS

In a nationwide HF cohort with reduced ejection fraction (HFrEF), we compared demographics, clinical characteristics, guideline-based therapy use and outcomes in non-cardiology vs. cardiology in-patient and out-patient care.

RESULTS

Between 2000 and 2016, 36,076 patients with HFrEF were enrolled in the Swedish HF registry (19,337 [54%] in-patients overall), with 44% of in-patients and 45% of out-patients managed in non-cardiology settings. Predictors of treatment in non-cardiology were age > 75 years (adjusted odds ratio for non-cardiology 1.20; 95% confidence interval 1.14-1.27), lower education level (0.71; 0.66-0.76 for university vs. compulsory), valve disease (1.24; 1.18-1.31) and systolic blood pressure (SBP) >120 mmHg (1.05; 1.00-1.10). Non-cardiology care was significantly associated with lower use of beta-blockers (0.80; 0.74-0.86) and devices (intracardiac defibrillator [ICD] and/or cardiac resynchronization therapy [CRT]: 0.63; 0.56-0.71), and less frequent specialist follow-up (0.61; 0.57-0.65). Over 1-year follow-up the risk of all-cause mortality (adjusted hazard ratio 1.09; 1.03-1.15) was higher but the risk of first HF (re-) hospitalization was lower (0.93; 0.89-0.97) in non-cardiology vs. cardiology care.

CONCLUSIONS

In HFrEF, non-cardiology care was independently associated with older ageand lower education. After covariate adjustment, non-cardiology care was associated with lower use of beta-blockers and devices, higher mortality, and lower risk of HF hospitalization. Access to cardiology care may not be equitable and this may have implications for use of guideline-based care and outcomes.

Roles of Nursing in the Management of Geriatric Cardiovascular Diseases

The nursing field occupies the largest secion of the cardiovascular healthcare services. Despite this, the roles of nursing within the cardiovascular healthcare system has not been well displayed. The authors searched PubMed and Embase (between January 1, 1950, and June 17, 2021) and created a narrative review of recent publications regarding the role of nursing in the management of geriatric cardiovascular disease (CVD). Patients with geriatric CVD, which includes mainly myocardial ischemia and heart failure, were enrolled. Nursing can improve the outcomes of myocardial ischemia and heart failure. It plays a pivotal role in the recovery, rehabilitation, and outcomes of geriatric CVD, especially for chronic heart diseases. Taken together, this paper compiled is focused on the current status of cardiovascular nursing and may facilitate future treatment and rehabilitation in geriatric CVD.

Phenotyping heart failure patients for iron deficiency and use of intravenous iron therapy: data from the Swedish Heart Failure Registry

AIMS

Iron deficiency (ID) is associated with poor prognosis regardless of anaemia. Intravenous iron improves quality of life and outcomes in patients with ID and heart failure (HF) with reduced ejection fraction (HFrEF). In the Swedish HF registry, we assessed (i) frequency and predictors of ID testing; (ii) prevalence and outcomes of ID with/without anaemia; (iii) use of ferric carboxymaltose (FCM) and its predictors in patients with ID.

METHODS AND RESULTS

We used multivariable logistic regressions to assess patient characteristics independently associated with ID testing/FCM use, and Cox regressions to assess risk of outcomes associated with ID. Of 21 496 patients with HF and any ejection fraction enrolled in 2017-2018, ID testing was performed in 27%. Of these, 49% had ID and more specifically 36% had ID-/anaemia-, 15% ID-/anaemia+, 29% ID+/anaemia-, and 20% ID+/anaemia+ (48%, 39%, 13%, 30% and 18% in HFrEF, respectively). Risk of recurrent all-cause hospitalizations was higher in patients with ID regardless of anaemia. Of 1959 patients with ID, 19% received FCM (24% in HFrEF). Important independent predictors of ID testing and FCM use were anaemia, higher New York Heart Association class, having HFrEF, and referral to HF specialty care.

CONCLUSION

In this nationwide HF registry, ID testing occurred in only about a quarter of the patients. Among tested patients, ID was present in one half, but only one in five patients received FCM indicating low adherence to current guidelines on screening and treatment.

Referral and access to heart function clinics: A realist review

RATIONALE, AIM, AND OBJECTIVES

Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics.

METHODS

Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory.

RESULTS

A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome).

CONCLUSION

Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.

Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

Heart failure drug titration, discontinuation, mortality and heart failure hospitalization risk: a multinational observational study (US, UK and Sweden)

AIMS

Use and dosing of guideline-directed medical therapy (GDMT) in patients with heart failure (HF) have been shown to be suboptimal. Among new users of GDMT in HF, we followed the real-life patterns of dose titration and discontinuation of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), beta-blockers, mineralocorticoid receptor antagonists (MRA) and angiotensin receptor-neprilysin inhibitors (ARNI).

METHODS AND RESULTS

New users were identified in health care databases in Sweden, UK and US between 2016-2019. Inclusion criterion was a recent HF hospitalization (HHF) triggering the initiation of GDMT. Patients were grouped by GDMT, i.e. ACEi, ARB, beta-blocker, MRA and ARNI, and stratified by initial dose. Follow-up was 12 months, until death or study end. Outcomes were dose titration within each drug class, discontinuation and first HHF or death. Dose/discontinuation follow-up was assessed daily based on the coverage length of a filled prescription and reported on day 365. New users of ACEi (n = 8426), ARB (n = 2303), beta-blockers (n = 10 476), MRA (n = 17 421), and ARNI (n = 29 546) were identified. Over 12 months, target dose achievement was 15%, 10%, 12%, 30%, and discontinuation was 55%, 33%, 24% and 27% for ACEi, ARB, beta-blockers and ARNI, respectively. MRA was rarely titrated and discontinuation rates were high (40%). Event rates for HHF or death ranged from 40.0-86.9 per 100 patient-years across the treatment groups.

CONCLUSION

Despite high risk of clinical events following HHF, new initiation of GDMT was followed by consistent patterns of low up-titration and early GDMT discontinuation in three countries with different health care and economies. Our data highlight the urgent need for moving away from long sequential approach when initiating HF treatment and for improving just-in-time decision support for patients and health care providers.

Improvement in left ventricular ejection fraction after pharmacological up-titration in new-onset heart failure with reduced ejection fraction

Objective

Recent studies have reported suboptimal up-titration of heart failure (HF) therapies in patients with heart failure and a reduced ejection fraction (HFrEF). Here, we report on the achieved doses after nurse-led up-titration, reasons for not achieving the target dose, subsequent changes in left ventricular ejection fraction (LVEF), and mortality.

Methods

From 2012 to 2018, 378 HFrEF patients with a recent (< 3 months) diagnosis of HF were referred to a specialised HF-nurse led clinic for protocolised up-titration of guideline-directed medical therapy (GDMT). The achieved doses of GDMT at 9 months were recorded, as well as reasons for not achieving the optimal dose in all patients. Echocardiography was performed at baseline and after up-titration in 278 patients.

Results

Of 345 HFrEF patients with a follow-up visit after 9 months, 69% reached ≥ 50% of the recommended dose of renin-angiotensin-system (RAS) inhibitors, 73% reached ≥ 50% of the recommended dose of beta-blockers and 77% reached ≥ 50% of the recommended dose of mineralocorticoid receptor antagonists. The main reasons for not reaching the target dose were hypotension (RAS inhibitors and beta-blockers), bradycardia (beta-blockers) and renal dysfunction (RAS inhibitors). During a median follow-up of 9 months, mean LVEF increased from 27.6% at baseline to 38.8% at follow-up. Each 5% increase in LVEF was associated with an adjusted hazard ratio of 0.84 (0.75–0.94, p = 0.002) for mortality and 0.85 (0.78–0.94, p = 0.001) for the combined endpoint of mortality and/or HF hospitalisation after a mean follow-up of 3.3 years.

Conclusions

This study shows that protocolised up-titration in a nurse-led HF clinic leads to high doses of GDMT and improvement of LVEF in patients with new-onset HFrEF.

Supplementary Information

The online version of this article (10.1007/s12471-021-01591-6) contains supplementary material, which is available to authorized users.

The Development of a Situation-Specific Nurse-Led Culturally Tailored Self-Management Theory for Chinese Patients With Heart Failure

INTRODUCTION

Self-management is essential for treating heart failure (HF). Culture influences the ability to cope, negotiate, and adopt self-management behaviors. However, current HF self-management interventions for Chinese patients do not take culture into consideration. The aim of this article is to describe the development of a situation-specific nurse-led culturally tailored self-management theory for Chinese patients with HF.

METHODOLOGY

An integrative approach was used as theory development strategy for the situation-specific theory.

RESULTS

Based on theoretical and empirical evidence, and theorists' experiences from research and practice, a nurse-led culturally tailored self-management theory for Chinese patients with HF was developed.

DISCUSSION

Researchers addressing health phenomena often have difficulty defining, conceptualizing, and operationalizing culture. The situation-specific theory developed in this study has the potential to increase specificity (i.e., logical adequacy and usefulness) of existing theories while informing the application to nursing practice. Further critique and testing of the situation-specific theory is warranted.

Acute heart failure – The ‘real’ Malaysian experience: An observational study from a single non-cardiac centre

Background:

Cardiovascular care in Malaysia adopts a ‘spoke-and-hub’ model, leaving the majority of acute heart failure (AHF) care to non-cardiac centres. Granular data on AHF care are essential and yet remain scarce.

Objectives:

This study aimed to illustrate the baseline characteristics, management and outcome of AHF patients.

Methods:

A retrospective, cross-sectional study was conducted on 1307 AHF patients admitted between 1 January 2012 and 31 December 2016.

Results:

The younger and Malay-predominant population reflects the distribution of ischaemic heart disease in Malaysia, highlighting the need to tackle metabolic risks factors. The majority are precipitated by ischaemia (61.8%). Common co-morbidities include hypertension (70.9%), coronary artery disease (57.8%) and diabetes (62.2%). The majority were of New York Heart Association Class II (31.9%) and Class III (25.6%). A total of 14.5% required inotropes and vasopressors, 12.9% required intravenous nitrates and 8.6% required dialysis. A further 4.9% of patients required intubation and mechanical ventilation, and 25.9% required non-invasive ventilation. Readmission and mortality were extremely high in our population. Short inpatient stays, restricting optimisation of medication, and gaps in the provision of coronary intervention and stress testing are possible contributing factors. When compared to global and regional registries, disparities were noted specifically surrounding mortality rate and optimum use of guideline-directed medical therapy.

Conclusion:

Although smaller and single centred, our study provides a unique insight into a pure Malaysian-only cohort from a hospital with no cardiology services in-house, which is more reflective of the majority of hospitals in Malaysia, unlike previous studies and registries.

Tools to Support Self-Care Monitoring at Home: Perspectives of Patients with Heart Failure

Self-care monitoring at home can be a challenge for patients with heart failure (HF). Tools that leverage information and communication technology (ICT), comprise medical devices, or have written material may support their efforts at home. The aim of this study was to describe HF patients’ experiences and their prioritization of tools that support, or could support, self-care monitoring at home. A descriptive qualitative design employing semi-structured interviews was used with HF patients living at home and attending an HF outpatient clinic in Norway. We used a deductive analysis approach, using the concept of self-care monitoring with ICT tools, paper-based tools, medical devices, and tools to consult with healthcare professionals (HCPs) as the categorization matrix. Nineteen HF patients with a mean age of 64 years participated. ICT tools are used by individual participants to identify changes in their HF symptoms, but are not available by healthcare services. Paper-based tools, medical devices, and face-to-face consultation with healthcare professionals are traditional tools that are available and used by individual participants. HF patients use traditional and ICT tools to support recognizing, identifying, and responding to HF symptoms at home, suggesting that they could be used if they are available and supplemented by in-person consultation with HCPs.

Nurse-Led Heart Failure Clinics Are Associated With Reduced Mortality but Not Heart Failure Hospitalization

Background Follow-up in a nurse-led heart failure ( HF ) clinic is recommended in HF guidelines, but its association with outcomes remains controversial, with previous studies including few and highly selected patients. Thus, large analyses of "real-world" samples are needed. Aims were to assess: (1) independent predictors of and (2) prognosis associated with planned referral to nurse-led HF clinics. Methods and Results We analyzed data from the SwedeHF (Swedish HF Registry) using multivariable logistic regressions to identify independent predictors of planned referral to a nurse-led HF clinic and multivariable Cox regressions to test associations between planned referral and outcomes (all-cause death, HF hospitalization, and their composite). Of 40 992 patients, 39% were planned to be referred to a follow-up in a nurse-led HF clinic. Independent characteristics associated with planned referral were shorter duration of HF , clinical markers of more-severe HF, such as lower ejection fraction, higher New York Heart Association class and N-terminal pro-B-type natriuretic peptide, and lower blood pressure, as well as cohabitating versus living alone, male sex, fewer comorbidities, and more use of HF treatments. After adjustments, planned referral to a nurse-led HF clinic was associated with reduced mortality and mortality/ HF hospitalization, but not HF hospitalization alone. Conclusions In this nation-wide registry, 39% of our identified HF cohort was planned to be referred to a nurse-led HF clinic. Planned referral reflected more-severe HF , but also sex- and family-related factors, and it was independently associated with lower risk of death, but not of HF hospitalization.

Inequalities in heart failure care in a tax-financed universal healthcare system: a nationwide population-based cohort study

Aims

Data on socioeconomic‐related differences in heart failure (HF) care are sparse. Inequality in care may potentially contribute to a poor clinical outcome. We examined socioeconomic‐related differences in quality of HF care among patients with incident HF with reduced ejection fraction (EF) (HFrEF).

Methods and results

We conducted a nationwide population‐based cohort study among patients with HFrEF (EF ≤40%) registered from January 2008 to October 2015 in the Danish Heart Failure Registry, a nationwide registry of patients with a first‐time primary HF diagnosis. Associations between individual‐level socioeconomic factors (cohabitation status, education, and family income) and the quality of HF care defined by six guideline‐recommended process performance measures [New York Heart Association (NYHA) classification, treatment with angiotensin‐converting‐enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), beta‐blockers and mineralocorticoid receptor antagonists, exercise training, and patient education] were assessed using multiple imputation and multivariable logistic regression controlling for potential confounders. Among 17 122 HFrEF patients included, 15 290 patients had data on all six process performance measures. Living alone was associated with lower odds of NYHA classification [adjusted OR (aOR) 0.81; 95% confidence interval (CI): 0.72–0.90], prescription of ACEI/ARB (aOR 0.76; 95% CI: 0.68–0.88) and beta‐blockers (aOR 0.84; 95% CI: 0.76–0.93), referral to exercise training (aOR 0.75; 95% CI: 0.69–0.81), and patient education (aOR 0.73; 95% CI: 0.67–0.80). Compared with high‐level education, low‐level education was associated with lower odds of NYHA classification (aOR 0.93; 95% CI: 0.79–1.11), treatment with ACEI/ARB (aOR 0.99; 95% CI: 0.81–1.20) and beta‐blockers (aOR 0.93; 95% CI: 0.79–1.09), referral to exercise training (aOR 0.73; 95% CI: 0.65–0.82), and patient education (aOR 0.86, 95% CI: 0.75–0.98). An income in the lowest tertile was associated with lower odds of NYHA classification (aOR 0.67; 95% CI: 0.58–0.79), prescription of ACEI/ARB (aOR 0.80, 95% CI: 0.67–0.95) and beta‐blockers (aOR 0.88, 95% CI: 0.86–1.01), referral to exercise training (aOR 0.59, 95% CI: 0.53–0.64), and patient education (aOR 0.66; 95% CI: 0.59–0.74) compared with an income in the highest tertile. Overall, no systematic differences were seen when the analyses were stratified by sex and age groups.

Conclusions

Living alone, low‐level education, and income in the lowest tertile were associated with reduced use of recommended processes of HF care among Danish HFrEF patients with a first‐time primary HF diagnosis. Efforts are warranted to ensure guideline‐recommended HF care to all HFrEF patients, irrespective of socioeconomic background.

Transitional Care Home Visits Among Underserved Patients With Heart Failure

Heart failure (HF), a global public health problem affecting 26 million people worldwide, significantly impacts quality of life. The prevalence of depression associated with HF is 3 times higher than that of the general population. Evidence, though, supports the use of transitional care as a method to enhance functional status and improve rates of depression in patients with HF. This article discusses the findings of a quality improvement project that evaluated health outcomes in underserved patients with HF who participated in a transitional care home visitation program. The visitation program exemplifies the role of leadership in facilitating transitions across the health care continuum. The 2-year retrospective review included 79 participants with HF. Comparisons of outcomes were made over 6 months. Although not statistically significant, clinically significant differences in health outcomes were observed in participants who received a home visit >14 days compared with ≤14 days after hospital discharge. A home visitation program for underserved patients with HF offers opportunities to enhance care across the continuum. Ongoing evaluation of the existing home visitation program is indicated over time with the goal of offering leaders data to enhance patient and family-centered transitional care coordination.

Association Between Use of Primary-Prevention Implantable Cardioverter-Defibrillators and Mortality in Patients With Heart Failure

Background:

Most randomized trials on implantable cardioverter-defibrillator (ICD) use for primary prevention of sudden cardiac death in heart failure with reduced ejection fraction enrolled patients >20 years ago. We investigated the association between ICD use and all-cause mortality in a contemporary heart failure with reduced ejection fraction cohort and examined relevant subgroups.

Methods:

Patients from the Swedish Heart Failure Registry fulfilling the European Society of Cardiology criteria for primary-prevention ICD were included. The association between ICD use and 1-year and 5-year all-cause and cardiovascular (CV) mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort and in prespecified subgroups.

Results:

Of 16 702 eligible patients, only 1599 (10%) had an ICD. After matching, 1305 ICD recipients were compared with 1305 nonrecipients. ICD use was associated with a reduction in all-cause mortality risk within 1 year (hazard ratio, 0.73 [95% CI, 0.60–0.90]) and 5 years (hazard ratio, 0.88 [95% CI, 0.78–0.99]). Results were consistent in all subgroups including patients with versus without ischemic heart disease, men versus women, those aged <75 versus ≥75 years, those with earlier versus later enrollment in the Swedish heart failure registry, and patients with versus without cardiac resynchronization therapy.

Conclusions:

In a contemporary heart failure with reduced ejection fraction population, ICD for primary prevention was underused, although it was associated with reduced short- and long-term all-cause mortality. This association was consistent across all the investigated subgroups. These results call for better implementation of ICD therapy.