Ambulatory management of acute decompensation in heart failure

Lee, Cheuk; Beleznai, Timea; Hassan, Salimah; Rawat, Anju; Douglas, Homeyra; Kanagala, Prathap; Sankaranarayanan, Rajiv

doi:10.12968/hmed.2019.80.1.40

Cited by 8 publications

(13 citation statements)

References 21 publications

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“…However, the admission rate for the HeartFailure@Home cohort is significantly lower than has been reported in previous studies. 5 , 7 , 26 …”

Section: Discussionmentioning

confidence: 99%

“… 4 In cases where self‐care or supervised up‐titration of oral diuretics have proved ineffective, evidence is growing to support the safe and effective administration of intravenous (IV) diuretics in a community setting. 5 , 6 , 7 Previous work has demonstrated that community‐based IV diuresis is cost‐effective and popular with patients. 6 Despite these findings, adoption of ambulatory IV diuretic therapy has not been widespread and has yet to be formally recommended in either European or North American guidelines.…”

Section: Introductionmentioning

confidence: 99%

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Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective

et al. 2021

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Aims This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service. Methods and resultsWe retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day-case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard-of-care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service-78 (68.4%) on a day-case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out-patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow-up, there were 20 (17.5%) 30 day re-admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard-of-care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P < 0.001). Conclusions Outpatient ambulatory management of decompensated HF with IV diuretics given either on a day case unit or in a domiciliary setting is feasible, safe, and effective in selected patients with decompensated HF. This should be explored further as a model in delivering HF services in the outpatient setting during COVID-19.

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“…However, the admission rate for the HeartFailure@Home cohort is significantly lower than has been reported in previous studies. 5 , 7 , 26 …”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective

et al. 2021

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“…There is no clear evidence that hospitalization improves outcome. 32 Treatment with intravenous diuretics in an outpatient setting could represent a viable alternative strategy for hospitalization. Patients with worsening HF have relatively slow onset and progression of symptoms that provides a window during which outpatient treatment may relieve symptoms without the need for emergency department presentation or hospitalization.…”

Section: Safety and Efficacy Of Outpatient Treatment Of Worsening Hfmentioning

confidence: 99%

“…25 In the United States, approximately 19% of hospitals have the possibility of outpatient treatment with intravenous or subcutaneous diuretics, and these treatments comprise 1.4% of all outpatient visits for HF.. 31 Outpatient treatment of patients with worsening HF could avoid delays when presenting to the emergency department and streamline standard disciplinary HF care and early follow-up after treatment. 32 Furthermore, complications of hospitalization could be prevented, such as venous thrombosis, phlebitis, hospital-acquired pneumonia, ulcers due to lack of mobility, loss of control, and depression, estimated to be as high as 25%. 34 Risk stratification and clinical decision making: choosing the right patient and right treatment for outpatient treatment of worsening HF…”

Section: Safety and Efficacy Of Outpatient Treatment Of Worsening Hfmentioning

confidence: 99%

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Outpatient treatment of worsening heart failure with intravenous and subcutaneous diuretics: a systematic review of the literature

Wierda¹,

Dickhoff²,

Handoko³

et al. 2020

ESC Heart Failure

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Aims In the coming decade, heart failure (HF) represents a major global healthcare challenge due to an ageing population and rising prevalence combined with scarcity of medical resources and increasing healthcare costs. A transitional care strategy within the period of clinical worsening of HF before hospitalization may offer a solution to prevent hospitalization. The outpatient treatment of worsening HF with intravenous or subcutaneous diuretics as an alternative strategy for hospitalization has been described in the literature. Methods and resultsIn this systematic review, the available evidence for the efficacy and safety of outpatient treatment with intravenous or subcutaneous diuretics of patients with worsening HF is analysed. A search was performed in the electronic databases MEDLINE and EMBASE. Of the 11 included studies 10 were single-centre, using non-randomized, observational registries of treatment with intravenous or subcutaneous diuretics for patients with worsening HF with highly variable selection criteria, baseline characteristics, and treatment design. One study was a randomized study comparing subcutaneous furosemide with intravenous furosemide. In a total of 984 unique individual patients treated in the reviewed studies, only a few adverse events were reported. Re-hospitalization rates for HF at 30 and 180 days were 28 and 46%, respectively. All-cause re-hospitalization rates at 30 and 60 days were 18-37 and 22%, respectively. The highest HF re-hospitalization was 52% in 30 days in the subcutaneous diuretic group and 42% in 30 days in the intravenous diuretic group. Conclusions The reviewed studies present practice-based results of treatment of patients with worsening HF with intravenous or subcutaneous diuretics in an outpatient HF care unit and report that it is effective by relieving symptoms with a low risk of adverse events. The studies do not provide satisfactory evidence for reduction in rates of re-hospitalization or improvement in mortality or quality of life. The conclusions drawn from these studies are limited by the quality of the individual studies. Prospective randomized studies are needed to determine the safety and effectiveness of outpatient intravenous or subcutaneous diuretic treatment for patient with worsening HF.

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Outpatient treatment of decompensated heart failure: A systematic review and study level meta‐analysis

Bahar,

Rahman,

Wong

et al. 2024

ESC Heart Failure

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Patients with acutely decompensated heart failure (ADHF) are usually admitted to hospital for management. There is growing interest in delivering intravenous (IV) diuretic therapy at home, in the community or at hospital day‐care units; the safety and effectiveness of outpatient‐based management (OPM) for ADHF has not been established. We conducted a systematic literature review and meta‐analysis to investigate the short‐term safety and effectiveness of OPM compared with inpatient management (IPM) of ADHF. Pre‐specified endpoints were 30 day mortality and 30 day hospitalization. The meta‐analysis was conducted using RevMan 5.4 software. Twenty‐nine studies of OPM were identified, including 7683 patients. Only five studies directly compared OPM (n = 1303) with IPM (n = 2047), including three observational studies, and two randomized controlled trials (RCTs). The other 24 studies only stated OPM outcomes. For the five studies comparing IPM versus OPM, patients were generally aged >75 years and of similar age for each strategy, with a similar proportion of men (56%). In a study‐level, aggregate analysis, 30 day all‐cause mortality was 9.3% (121/1303) for OPM, compared with 15.6% (320/2047) for IPM [OR 0.29 (95% CI 0.09, 0.93) P = 0.04]. Four studies reported 30 day all‐cause hospitalization; 22.0% for IPM versus 16.8% for OPM [OR 0.73 (95% CI 0.61, 0.89), P = 0.001]. In the two RCTs, we found no difference in 30 day mortality or hospitalization. In observational studies, OPM of ADHF is associated with lower 30 day hospitalization and lower 30 day mortality; such differences were not observed in two small, single‐centre RCTs. A substantial, multicentre RCT is required to confirm the safety and effectiveness of OPM for ADHF.

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Ambulatory management of acute decompensation in heart failure

Cited by 8 publications

References 21 publications

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective

Outpatient treatment of worsening heart failure with intravenous and subcutaneous diuretics: a systematic review of the literature

Outpatient treatment of decompensated heart failure: A systematic review and study level meta‐analysis

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