Background We sought to investigate the impact of the COVID-19 pandemic and the Tele-HF Clinic (Tele-HFC) program on cardiovascular death, heart failure (HF) rehospitalization, and heart transplantation rates in a cohort of ambulatory HF patients during and after the peak of the pandemic. Methods Using the HF clinic database, we compared data of patients with HF before, during, and after the peak of the pandemic (January 1 to March 17 [pre-COVID], March 17 to May 31 [peak-COVID], and June 1 to October 1 [post-COVID]). During peak-COVID, all patients were managed by Tele-HFC or hospitalization. After June 1, patients chose either a face-to-face clinic visit or a continuous tele-clinic visit. Results Cardiovascular death and medical titration rates were similar in peak-COVID compared with all other periods. HF readmission rates were significantly lower in peak-COVID (8.7% vs. 2.5%, p<0.001) and slightly increased (3.5%) post-COVID. Heart transplant rates were substantially increased in post-COVID (4.5% vs. peak-COVID [0%], p = 0.002). After June 1, 38% of patients continued with the Tele-HFC program. Patients managed by the Tele-HFC program for <6 months were less likely to have HF with reduced ejection fraction (73% vs. 54%, p = 0.005) and stage-D HF (33% vs. 14%, p = 0.001), and more likely to achieve the target neurohormonal blockade dose (p<0.01), compared with the ≥6-month Tele-HFC group. Conclusions HF rehospitalization and transplant rates significantly declined during the pandemic in ambulatory care of HF. However, reduction in these rates did not affect subsequent 5-month hospitalization and cardiovascular mortality in the setting of Tele-HFC program and continuum of advanced HF therapies.
Objectives The aims of the study were: (1) to determine the pattern of myocardial fibrosis assessed by delayed gadolinium enhancement cardiac MRI (DGE-CMRI) in patients with heart failure improved ejection fraction (HF-iEF) in an advanced heat failure clinic; and (2) to examine the dosage of beta-blocker and angiotensin converting enzyme inhibitor/ angiotensin receptor blockage/angiotensin neprilysin inhibitor (ACE-I/ARB/ARNI) in those patients. Methods HF-iEF was defined as patients with LVEF >40% with previously documented LVEF <35% at baseline. Results Among 312 consecutive patients with HF-rEF who were referred for an advanced HF clinic, 18% (56 patients) had HF-iEF within 12 months after referral. Of these, 84% (47 patients) had non-ischemic cardiomyopathy (CM); complete data on MRI for analysis were available for 25 of these patients (62%). Myocardial scar was found in 52% of patients with nonischemic CM (13 of 25). All patients with nonischemic CM had the myocardial scar of less than 10% of the total LV volume. Mid-wall DGE of the interventricular septum was the most common scar pattern. Among patients with HF-iEF, 36% (20 patients) were referred for heart transplant. Two patients with peripartum related and nonischemic etiologies were listed for heart transplant, and delisted 12 months after. No patient died during 1-year follow up. At 12 months, the mean LVEF change was +27±12%. Improvement of the LVEF to ≥50% occurred in 31 patients (55%). The percentage use of ACE-I/ARB/ARNI and beta-blocker was significantly increased, at 1-year-follow-up. Fourteen percent and 48% of patients achieved target dose of ACE-I/ARB/ARNI and beta-blocker, respectively. There was no significant association between myocardial scar pattern or extent and dosage of medical titration. Conclusions HF-iEF was present in 18% of patients with HF-rEF after 1-year follow-up in advanced heart failure clinic. Mid-wall DGE of the interventricular septum was the most common scar pattern in nonischemic HF-iEF. None of patients with nonischemic HF-iEF had myocardial scar >10% of the total LV volume. Improvement of LVEF to ≥50% occurred in approximately half of the study patients, and led to delisting patients from heart transplant waiting list. The majority of patients had recovery of the LVEF when the target dose of beta-blocker or ACE-I/ARB/ARNI had not been achieved during medical up-titration. Funding Acknowledgement Type of funding source: None
Objectives To assess 1-year outcomes of patients with heart failure with reduced ejection fraction (HF-rEF) who referred to a multidisciplinary heart failure (HF) clinic for advanced HF therapy. Methods We studied consecutive 312 ambulatory patients (mean age 51 years, 79% male) with HF-rEF (mean EF 23±8%) who were referred from cardiologists and cardiac surgeons to a multidisciplinary advanced HF clinic. The study patients were divided into 3 groups based on HF/transplant cardiologist evaluation. Group A consisted of 65 patients who were listed for heart transplant (HTx). Group B consisted of 157 patients who were considered as potential HTx candidates but who were too well to be listed for HTx. All patients in this group were not on optimal medical therapy (OMT) for HF-rEF at the time of evaluation. Group C consisted of 90 patients who were not suitable for HTx. Primary outcomes included HTx, left ventricular assist device (LVAD), or death. Outcomes were assessed at baseline and at 1 year after referral Results During the mean follow-up period of 9.6±4.1 months, 88 primary outcomes (28%) occurred (43 deaths (14%), 42 HTxs (14%) and 3 LVAD implants (1%)). Patients in group A, B, and C had a1-year survival of 91%, 90%, and 78%, respectively. At 1-year follow-up, 59%, 3%, and 0% in patients in group A, B, and C underwent HTx. The median waiting time for HTx was 5 months. At 1 year after referral, there was a 20%, 92%, and 63% reduction in HF admission in group A, B, and C, respectively; 44 HF admissions (0.2%/patients) occurred at 1 year after referral, compared with 530 HF admissions (1.7%/patients) 1 year before referral (p<0.001). There was a significant increased rate of β-blocker (BB) use at 1 year (69% vs. 95% receiving BB, p<0.001; and 5% vs. 43% receiving target dose of BB, p<0.001). There was also an increased use of angiotensin converting enzyme inhibitor (ACE-I) /angiotensin receptor blocker (ARB)/ angiotensin receptor Neprilysin inhibitor (ARNI) (68% vs. 88% receiving ACE/ARB/ARNI, p<0.01; and 6% vs. 17% achieving target dose, p<0.01). The increase in utilization of BB and ACE/ARB/ARNI was evident across the 3 groups. LVEF recovery at 1 year occurred in 2%, 28%, and 6% in patients in group A, B, and C. Ten patients in group A (15%) were delisted for clinical improvement. Peak oxygen consumption improved after 1-year referral (13.9 vs. 19.5 ml/kg/min, p<0.01). Conclusions In the contemporary treatment of HF, a multidisciplinary HF clinic led to improved optimal medical therapy (OMT), and an 88% reduction in HF admission in ambulatory patients with HF-rEF. The impact of these benefits was evident across the entire spectrum of HF severity particularly patients who were considered as potential HTx candidates but who were not on OMT (50% of referrals). About a third had LVEF recovery after intensive medical therapy. These findings suggested that OMT and intensive multidisciplinary HF care may prevent overtreatment HTtx. Funding Acknowledgement Type of funding source: None
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