Preventing Heart Failure Hospitalizations: The Need for a Provincial Strategy

Submitted by: Dr. Sean A. Virani

Averting hospitalization for disease decompensation continues to be a challenge for heart failure (HF) care providers. Acute decompensated heart failure (ADHF) is a major public health concern which is associated with significant morbidity, mortality and healthcare utilization.

At present, there are in excess of 90,000 British Columbians living with HF, all of whom are at risk for hospitalization given the natural history of their disease process. In fact, approximately three-quarters of all patients admitted to hospital with ADHF have an established HF diagnosis. once admitted to hospital, these individuals have a one year mortality of 33% and a risk of re-hospitalization for HF at one year of 24%. In 2009, the cost of hospitalization related to HF in BC topped out at over $300 million dollars per year1.

It is estimated that improved care processes including adherence with prescribing evidence- based therapies for HF (e.g. beta blockers and inhibitors of the renin-angiotensin-aldosterone system), heart failure education and systematic out-patient follow-up through HF clinics could avert up to 50% of hospitalizations attributable to HF. In 2010, only 64% of eligible British Columbians with a diagnosis of HF received an ACE-inhibitor or angiotensin receptor blocker, while only 40% of eligible patients received a beta-blocker1. Under prescribing of these efficacious evidence-based therapies remains a major barrier to better outcomes in HF patients and an important determinant of hospitalization for ADHF.

In the last few years a number of clinical trials have been undertaken to evaluate the efficacy of novel pharmacological agents to improve clinical outcomes and rehospitalization among those admitted to hospital with ADHF. Regrettably, none of these trials were able to demonstrate positive results and a few were stopped early with the suggestion of harm. As such, at present, the best way to mitigate the poor outcomes associated with ADHF is to prevent the index hospitalization all together.

Improved out-patient monitoring of HF patients at high risk for hospitalization (e.g. those with low ejection fraction or advanced functional symptoms) is an important and innovative strategy that is gaining momentum and one that has the potential for significantly impacting HF hospitalization. With enhanced technology and remove monitoring, HF care providers can now follow important haemodynamic and clinical variables in their patients who have been implanted with a defibrillator (ICD), biventricular pacemaker (also known as cardiac resynchronization therapy, CRT) or both (CRT-D). Trends in fluid status can be identified early and appropriate medical therapies can be adjusted so as to avert a hospitalization. Moveover, patients with stable parameters on remote monitoring may not require as frequent follow up as those with instability, thereby creating capacity within the system and decreasing healthcare utilization.

The recent PARTNERS-HF trial2 was a prospective observational study of remote monitoring in patients with NYHA functional class III symptoms who had previously received a CRT-D device. The study was designed to evaluate the accuracy of a novel diagnostic algorithm in determining the likelihood of hospitalization for pulmonary edema among study participants within the next 30 days. The algorithm used in the study was based upon a number of important variables including fluid status, autonomic function, patient activity and arrhythmia burden. Compared to patients with a negative diagnostic, those with a positive diagnostic were 5.5 fold more likely to be admitted to hospital with pulmonary edema within 30 days. The authors concluded that remote patient monitoring utilizing this technology could identify individuals at high risk for disease decompensation, thereby allowing clinicans to intervene early and prevent hospitalizations.

Remote monitoring to avert HF hospitalization is a quickly expanding field. Technological advancements include complex algorithms that integrate clinical variables such as weight and blood pressure3, as well as newer and smaller intracardiac haemodynamic monitoring systems4-5. In the CHAMPION trial4, study participants that received an implantable pulmonary artery pressure monitoring device and who were followed remotely had a 39% reduction in heart failure related hospitalizations compared to control patients at 15 months. The HOMEOSTASIS trial5 showed that remote monitoring of patients with advanced HF implanted with a direct left arterial pressure sensor resulted in improvements in a variety of clinical and patient related outcomes. Even more compelling was that any changes to therapy that occurred as a result of remote monitoring data were patient self-managed, including up- titration of diuretics.

Admission to hospital for HF is associated with poor patient related and healthcare system related outcomes. Thoughtful application of new monitoring technologies along with the optimal use of existing treatment strategies and care processes is paramount to decreasing the burden of HF hospitalization in BC.

1. BC Ministry of Health Services, 2010
2. Whellan DJ, Ousdigian KT et al. (2010) Combined heart failure device
    diagnostics identify patients at higher risk of subsequent heart failure
    hospitalizations: results from PARTNERS HF (Program to Access and Review
    Trending Information and Evaluate Correlation to Symptoms in Patients With Heart Failure) study. JACC 55:1803:10.
3. Boehmer JP, Saxon LA et al. (2009) Active Remote Management and Device
    Monitoring in Patients with HF Results in Frequent Interventions: Results
    from the RAPID-RF Registry. HRS Annual Scientific Sessions. Abstract 6367
4. Abraham WT, Admason PB et al. (2011) Wireless pulmonary artery
     haemodynamic monitoring in chronic heart failure: a randomized control trial. Lancet 377:658-666.
5. Ritzema J, Troughton R et al. (2010) Physician-directed patient self-
     management of left atrial pressure in advanced chronic heart failure.
     Circulation 121:1086-1095

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