Heart failure is associated with a high rate of readmissions within 30 days postdischarge. Strategies designed to lower readmission rates generally show modest results, especially in elderly and frail patients with mainly preserved ejection fraction. Moreover, assessing death and readmission risks is difficult in this high-risk population, and prognostic data including biomarkers are scarce. In order to reduce readmission rates and to assess risk, we developed a STructured multidisciplinary outpatient clinic for Old and frail Postdischarge patients hospitalized for heart failure (STOP-HF-Clinic). This prospective all-comers study enrolled consecutive patients discharged mainly from internal medicine or geriatric wards after heart failure hospitalization. The intervention involved an early visit within 7 days, with several medical, educational, diagnostic, therapeutic and transitional actions. Blood samples were obtained to analyze biomarkers, including circulating levels of ST2, NT-proBNP, CA125, and hs-TnI. Patients were followed in successive visits as freqüently as needed, during a 30-day follow up. 518 consecutive patients were included with an average age of 82 years-old, 57,1% were women. The CORE-HF 30-day readmission risk was 26,5%. The observed all-cause 30-day readmission rate was 13,9% (47,5% relative risk reduction) and the observed heart failure-related 30-day readmission rate was 7,5%. The 30-day readmission rate was significantly reduced in the STOP-HF-Clinic Referral Area after the intervention (2014-2015 period) compared with pre-intervention period (2012-2013) mainly driven by fewer heart failure-related readmissions. The composite endpoint (death or heart failure readmission) ocurred in 8,6% patients at 30 days and in 38,5% at 1 year. In multivariable analysis, ST2 was the only predictive biomarker at 30 days; at 1 year, both ST2 and NT-proBNP remained significant. The addition of ST2 and NT-proBNP into a clinical predictive model increased the AUC from 0,70 to 0.75 at 30 days (p = 0,02) and from 0,71 to 0,74 at 1 year (p < 0,05). For all-cause death at 1 year, ST2 and CA125 remained independent predictors in multivariable analysis. The addition of ST2 and CA125 into a clinical predictive model increased the AUC from 0,74 to 0,78 (p = 0,03). For HF-related hospitalizations, ST2 was the only predictive biomarker in multivariable analyses, both at 30 days and at 1 year. In conclusion, the STOP-HF-Clinic is a valuable intervention for reducing the global burden of early readmissions among elder and vulnerable patients with heart failure. In such a comorbid and elderly population with heart failure with preserved ejection fraction, ST2 as a surrogate marker of inflammation and fibrosis outperformed NT-proBNP for predicting the risk of all-cause mortality or heart failure-related rehospitalization.
Impacte d'una consulta de suport a l'ingrés per insuficiència cardíaca.
Pacho Pacho, C. (Author). 26 Sept 2019
Student thesis: Doctoral thesis
Student thesis: Doctoral thesis