Treating Patients Following Hospitalisation for Acute Decompensated Heart Failure: An Insight into Reducing Early Rehospitalisations

Initiating ivabradine during hospitalization in patients with acute heart failure: A real‐world experience in China

Background

Initiating ivabradine in acute heart failure (HF) is still controversial.

Hypothesis

Ivabradine might be effective to be added in acute but hemodynamically stable HF.

Methods

A retrospective cohort of hemodynamically stable acute HF patients was enrolled from January 2018 to January 2020 and followed until July 2020. The primary endpoints were all‐cause mortality and rehospitalization for HF. Secondary endpoints included heart rate (HR), cardiac function measured by New York Heart Association (NYHA) class, and left ventricular ejection fraction (LVEF) and adverse events, which were compared between patients with or without ivabradine.

Results

A total of 126 patients were enrolled (50 males, median age 54 years, 81% with decompensated HF, median follow‐up of 9 months). In patients treated with ivabradine, although baseline HRs were higher than the reference group (96 vs. 80 bpm), they were comparable after 3 months; more patients tolerated high doses of β‐blockers (27% vs. 7.9%), improved to NYHA class I function (55.6% vs. 23.8%) and exhibited normal LVEFs (37.8% vs. 14.3%) than the reference group (all p < .05). Ivabradine was associated with a significant reduction of rehospitalization for HF than the reference group (25.4% vs.61.9%), with longer event‐free survival times (hazard ratio: 0.45, 95% confidence interval [CI]: 0.25–0.79), and was related with primary endpoints negatively (hazard ratio 0.51, 95% CI: 0.28–0.91) (all p < .05).

Conclusion

In patients with acute but hemodynamically stable HF, ivabradine may significantly reduce HR, improve cardiac function, and reduce HF rehospitalization.

Cardiac rehabilitation and all-cause mortality in patients with heart failure: a retrospective cohort study

AIMS 

Despite the benefits of exercise training in the secondary prevention of cardiovascular disease, there are conflicting findings for the impact of exercise-based cardiac rehabilitation (CR) on mortality for patients with heart failure (HF). The aim of this study was therefore to investigate the association of exercise-based CR with all-cause mortality, hospitalisation, stroke, and atrial fibrillation in patients with heart failure.

METHODS AND RESULTS

A retrospective cohort study was conducted which utilized a global federated health research network, primarily in the USA. Patients with a diagnosis of HF were compared between those with and without an electronic medical record of CR and/or exercise programmes within 6 months of an HF diagnosis. Patients with HF undergoing exercise-based CR were propensity score matched to HF patients without exercise-based CR by age, sex, race, comorbidities, medications, and procedures (controls). We ascertained 2-year incidence of all-cause mortality, hospitalization, stroke, and atrial fibrillation. Following propensity score matching, a total of 40 364 patients with HF were identified. Exercise-based CR was associated with 42% lower odds of all-cause mortality [odds ratio 0.58, 95% confidence interval (CI): 0.54-0.62], 26% lower odds of hospitalization (0.74, 95% CI 0.71-0.77), 37% lower odds of incident stroke (0.63, 95% CI 0.51-0.79), and 53% lower odds of incident atrial fibrillation (0.47, 95% CI 0.4-0.55) compared to controls, after propensity score matching. The beneficial association of CR and exercise on all-cause mortality was consistent across all subgroups, including patients with HFrEF (0.52, 95% CI 0.48-0.56) and HFpEF (0.65, 95% CI 0.60-0.71).

CONCLUSION 

Exercise-based CR was associated with lower odds of all-cause mortality, hospitalizations, incident stroke, and incident atrial fibrillation at 2-year follow-up for patients with HF (including patients with HFrEF and HFpEF).

Nurse-led ambulatory care supported by non-invasive haemodynamic assessment after acute heart failure decompensation

Heart failure (HF) is characterized by frequent decompensation and an unpredictable trajectory. To prevent early hospital readmission, coordinated discharge planning and individual therapeutic approach are recommended.

Aims

We aimed to assess the effect of 1 month of ambulatory care, led by nurses and supported by non‐invasive haemodynamic assessment, on the functional status, well‐being, and haemodynamic status of patients post‐acute HF decompensation.

Methods and results

This study had a multicentre, prospective, and observational design and included patients with at least one hospitalization due to acute HF decompensation within 6 months prior to enrolment. The 1 month ambulatory care included three visits led by a nurse when the haemodynamic state of each patient was assessed non‐invasively by impedance cardiography, including thoracic fluid content assessment. The pharmacotherapy was modified basing on haemodynamic assessment. Sixty eight of 73 recruited patients (median age = 67 years; median left ventricular ejection fraction = 30%) finished 1 month follow‐up. A significant improvement was observed in both the patients' functional status as defined by New York Heart Association class (P = 0.013) and sense of well‐being as evaluated by a visual analogue score (P = 0.002). The detailed patients' assessment on subsequent visits resulted in changes of pharmacotherapy in a significant percentage of patients (Visit 2 = 39% and Visit 3 = 44%).

Conclusions

The proposed model of nurse‐led ambulatory care for patients after acute HF decompensation, with consequent assessment of the haemodynamic profile, resulted in: (i) improvement in the functional status, (ii) improvement in the well‐being, and (iii) high rate of pharmacotherapy modifications.