06 November 2022
3 minutes of reading
Lee DS, et al. LBS.02. Breaking Science: Innovative Strategies in the HF Journey. Presented at: American Heart Association Scientific Sessions; November 5-7, 2022; Chicago (hybrid meeting).
Lee does not report relevant financial disclosures. Van Spall reports receiving research support from the Canadian Institutes of Health Research and McMaster University.
CHICAGO: Use of a point-of-care tool to support clinical decision making, in addition to rapid outpatient follow-up, reduced the risk of death or CV hospitalizations for patients with acute heart failure presenting to the ED.
“Implementation of this approach may lead to a path to earlier hospital or emergency department discharge and better patient outcomes.” Douglas S. Lee, MD, PhD, FRCPC, the Ted Rogers Chair in Cardiac Function Outcomes and University Health Network Peter Munk Heart Center staff cardiologist and professor of medicine at the University of Toronto, during a presentation at the American Heart Association Scientific Sessions.
Impact of the intervention on the results
The COACH trial was conducted to determine whether a strategy of using the Emergency Heart Failure Mortality Risk Score for 30-day mortality (EHMRG30-ST), a validated risk algorithm, in the emergency department in conjunction with with rapid standardized outpatient follow-up improves clinical outcomes.
The staggered cluster randomized clinical trial was conducted in 10 hospitals in Ontario, Canada, which underwent randomization at staggered start dates to cross over from the control phase, when the hospitals did not have access to the EHMRG30-ST tool, until the implementation of the intervention. . In the intervention phase, patients considered low risk were discharged within 3 days and received standardized outpatient care, while those considered high risk were admitted.
The trial included 5,452 patients presenting to the emergency department with acute heart failure. Of these, 2,972 were enrolled during the control phase and 2,480 during the intervention phase.
Within 30 days, use of the intervention strategy led to a 12% lower risk of death from any cause or hospitalization for cardiovascular causes, which occurred in 12.1% of patients included during the intervention phase compared with 14.5% of patients included preintervention (adjusted HR=0.88, 95% CI, 0.78-0.99; P = .04). In addition, the risk of hospitalization for CV causes was lower during the intervention phase (HRa = 0.85; 95% CI, 0.74-0.98), as was the risk of hospitalization for HF (HRa = 0, 81; 95% CI, 0.69-0.95), depending on the results
Within 20 months, the composite endpoint occurred in 54.4% of patients during the intervention phase compared to 56.2% during the control phase (HRa=0.95; 95% CI %, 0.92-0.99). Again, the intervention appeared to be associated with a lower risk of hospitalization for cardiovascular causes and HF, Lee said.
In other results, early discharge occurred in 27% of high-risk patients included in the control phase and in 19.1% of high-risk patients included in the intervention phase, in 44.2 % and 50.7% of intermediate-risk patients and in 58.2% and 57% of low-risk patients, respectively. Among low-risk patients discharged early, the median time to first outpatient visit was 4 days for those enrolled in any phase, and the median time to first outpatient visit with an internist or cardiologist was 6 days for those enrolled in any phase. those enrolled during the intervention phase and 12 days for those enrolled during the control phase. Among high-risk patients discharged early, the median time to first outpatient visit was slightly longer at 5 days for those enrolled in either phase, and the median time to first outpatient visit with an internist or cardiologist was 11 and 13 days, respectively, according to the results.
The investigators reported no deaths or hospitalizations from any cause in patients considered low or intermediate risk before the first outpatient visit within 1 week, and fewer than six events within 30 days of discharge.
‘Important implications for the use of health resources’
During a discussion about the trial after the presentation, Harriette Van Spall, MD, MPH, associate professor of medicine in the department of health research methods, evidence and impact at McMaster University, said: “This trial adds important information to fill a large knowledge gap about how to stratify risk and care for patients who present in the emergency department with heart failure.
“Our interference is that among hemodynamically stable patients presenting to the ED for heart failure, in the absence of instability, the clinical endpoints of 30-day death or CV hospitalization are reduced by 12% due to this important intervention. and the outcome at 20 months of death or CV hospitalization is reduced by 5%. This has important implications for health resource utilization and once we are clear about the endpoints of the admitted vs. discharged process in both groups, we will be able to assess the overall health care utilization of this intervention.”
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