After Acute HF Admission, Specialist Care Tied to Better Long-term Outcomes

Patients who receive care from a specialized team after being discharged from an acute heart failure (HF) hospitalization fare better over the long term than those who do not, according to data from a single county in the United Kingdom.

Being managed by a team of specialist nurses under the direct supervision of a cardiologist with an interest in HF was associated with a lower risk of all-cause death or rehospitalization for acute HF through a median follow-up of about 20 months, lead author Jonathan Raby, MB BCh (Buckinghamshire Healthcare NHS Trust and University of Oxford, England), and colleagues report in a paper published online recently in Open Heart.

The relationship was consistent across the range of LVEF, including patients with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fractions.

It’s not particularly surprising to find an association between specialist care and better outcomes, senior author Mayooran Shanmuganathan, MBBS, DPhil (Buckinghamshire Healthcare NHS Trust and University of Oxford), told TCTMD. But he noted that in the UK, many of these services have been reserved for patients with HFrEF, who up until recently had the most proven guideline-directed medical therapies (GDMT) available to them.

Over the past several years, however, evidence has emerged that the sodium-glucose cotransporter 2 (SGLT2) inhibitors and finerenone (Kerendia; Bayer) improve outcomes in patients with HFmrEF or HFpEF.

In that context, the researchers say, “our data support the expansion of outpatient multidisciplinary HF specialist care to all HF patients,” regardless of LVEF, age, and comorbidities.

Longer Follow-up

Though specialist care has been tied to better outcomes after an admission for acute HF admission before, prior research has largely focused on endpoints measured at 30 days or 1 year.

To expand on that, Raby et al performed a retrospective analysis of 2,104 patients (median age 83 years; 47% women) who were hospitalized with acute HF between March 2014 and April 2022 in Buckinghamshire, England, a county with a total population of about 550,000. Most patients (55%) had HFpEF (LVEF ≥ 50%), 9% had HFmrEF (LVEF 41% to 49%), and 36% had HFrEF (LVEF ≤ 40%).

During the index admission, which lasted a median of 5 days, 13% of patients died and 61% received input from the HF team.

Of those who survived to discharge, 61% had HF specialist care arranged for the outpatient setting, with higher rates seen in patients with HFrEF (79%) and HFmrEF (77%) versus those with HFpEF (53%). The median time to the first outpatient appointment was 43 days. Many patients (38%), however, did not show up for their first appointment.

Median follow-up duration for patients who survived to discharge after their index admission was 618 days. Over that span, 21% were rehospitalized for acute HF and 63% died. The rate of a composite of those two outcomes was 68%.

I think there will be a stronger business case to at least achieve that level of specialist nursing cover in the community. Mayooran Shanmuganathan

The researchers performed a survival analysis of 1,511 patients who had echocardiographic data available for LVEF stratification, showing that after adjustment for age, comorbidities, and discharge medication regimen, HF specialist care in the outpatient setting was associated with a lower risk of all-cause death or rehospitalization for acute HF. This was observed in patients with HFrEF (HR 0.58; 95% CI 0.43-0.78), HFmrEF (HR 0.49; 95% CI 0.28-0.83), and HFpEF (HR 0.76; 95% CI 0.62-0.93).

“The importance of outpatient HF specialist care for HFrEF makes intuitive sense given the opportunity to commence and uptitrate prognostically important GDMT. In our study, patients seen by the HF team after discharge were indeed more likely to end up on ‘three pillars’ of GDMT,” the authors write, noting that the SGLT2 inhibitors—a fourth pillar of HFrEF treatment—were not widely used during the study period.

A role for specialty care had been less clear for HFpEF, however, “and hence its association with better long-term outcomes in our study is striking,” Raby et al say. “As well as optimizing fluid status, the HF team may improve outcomes in HFpEF by optimizing management of ‘upstream’ comorbidities (such as obesity, hypertension and atrial fibrillation) that are increasingly recognized as drivers for the development of HFpEF pathophysiology.”

Expanding Services to More HF Patients

Asked how feasible it would be to offer specialist care in the outpatient setting to all patients with HF, Shanmuganathan said it should be expanded with an eye toward studying the impact on waiting list times for specialized care. 

“Once we open up the stream of referrals and expand the service provision to other patients with heart failure, including mildly reduced as well as preserved LV ejection fraction, we will then be able to establish more efficient pathways, hopefully, as well as ask funders and people with the money to be able to provide the right network,” he said.

Though all patients should receive some type of specialist care after an acute HF hospitalization, what that will look like will vary by patient, Shanmuganathan said. “But it needs to be a follow-up, and we need to figure out what it is that we’re going to provide for the different types of heart failure patients.”

That additional research is critical to ensure that scarce resources are used appropriately, he added. “The population with heart failure is ever expanding, and I’m not sure that cardiologists and heart failure nurses alone can cope with this.”

He noted that the British Society for Heart Failure (BSHF) has been advocating for an expansion of community HF nursing support, which currently involves one specialist nurse for every 100,000 people. The BSHF has called for up to four nurses per 100,000 people in response to the increasing complexity of medical treatments for HF and the aging population.

“Now that we have this kind of data, which I’m pretty sure would be replicated if other counties did the same analysis, I think there will be a stronger business case to at least achieve that level of specialist nursing cover in the community,” Shanmuganathan said. “And that should help us achieve follow-up for the majority of, if not all of, the patients that I’m proposing, which is all patients with heart failure to have a follow-up.”