Hospital-Based Strategy Lowers Risk of Death in Patients with Acute Heart Failure

Douglas S. Lee, MD, PhD

A hospital-based strategy to aid clinical decision making was associated with a lower risk of a composite of death from any cause or hospitalization for cardiovascular causes compared with usual care for patients with acute heart failure presenting to the emergency department.

Within 30 days after presentation, the intervention led to a 12% lower risk of the outcomes and led to a lower risk of death from any cause or hospitalization for cardiovascular causes within 20 months.

“Implementation of this approach may lead to a pathway for early discharge from the hospital or emergency department and improved patient outcomes,” wrote lead author Douglas S. Lee, MD, PhD, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University of Toronto.

The late-breaking findings were presented at the American Heart Association Scientific Sessions 2022 in Chicago.

Individuals who present to the emergency department with acute heart failure are often hospitalized, with clinicians often relying on clinical judgment to determine the path forward to admit or discharge patients. As a result, some high-risk patients are discharged home from the emergency department and some lower-risk patients are hospitalized, when they could be discharged and followed in ambulatory care.

The stepped-wedge, cluster-randomized, Comparison of Outcomes and Access to Care for Heart Failure (COACH) trial randomly assigned 10 hospitals to staggered start dates for one-way crossover from the control phase to the intervention phase. The intervention included a point-of-care algorithm (Emergency Heart Failure Mortality Risk Grade for 30-day mortality [EHMRG30-ST]) to strategy patients with acute heart failure according to risk of death.

Lower risk patients who were discharged from the emergency department or after a short observation period of 3 days or less in the hospital and received standardized outpatient care, while high-risk patients were admitted to the hospital. The acute HF risk stratification algorithm was housed on a central server and was accessible to sites only after crossover to active intervention.

The two co-primary outcomes were the 30-day composite of all-cause death or cardiovascular hospitalization (early) and 20-month composite of all-cause death or cardiovascular hospitalization (late). The outcomes were determined by linking clinically obtained data with administrative databases.

The statistical analyses used Cox proportional hazards models for time-to-event and logistic regression for binary outcomes. The models adjusted for step, hospital teaching status, annual HF patient volume, and accounted for within-hospital clustering.

A total of 5452 patients were enrolled in the trial, made up of 2972 patients during the control phase and 2480 patients during the intervention phase.

Within 30 days, death from any cause or hospitalization for cardiovascular causes occurred in 301 patients (12.1%) who were enrolled during the intervention phase and in 430 patients (14.5%) enrolled during the control phase (adjusted hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.78 - 0.99; P = .0.04).

Then, within 20 months, the cumulative incidence of primary-outcome events was 54.4% (95% CI, 48.6 to 59.9) among patients enrolled during the intervention phase and 56.2% (95% CI, 54.2 to 58.1) among patients enrolled during the control phase (adjusted HR, 0.95; 95% CI, 0.92 to 0.99).

Investigators noted fewer than six deaths or hospitalizations for any cause occurred in low- or intermediate-risk patients before the first outpatient visit within 30 days after discharge.

“The ability to prognosticate more accurately may enable physicians to make informed decisions about appropriate care settings, may enhance safety by reducing discharge of high-risk patients, and may improve efficiency by reducing admission of lower-risk patients,” added Lee.

The study “Trial of an Intervention to Improve Acute Heart Failure Outcomes,” was published in The New England Journal of Medicine.