Heart failure (HF) hospitalisations are commonly associated with increased mortality and morbidity. The multi-disciplinary HF workgroup was formed in 2016 comprising Cardiologists, HF Case Managers, ...Advanced Practice Nurses, Cardiac Pharmacists, Allied Health Professionals and Operations personnel. The group focuses on delivering an end-to-end HF care, that aims to improve clinical and functional outcomes, while keeping cost affordable to patients. Our early initiatives were targeted at the inpatient phase; with current shift towards patient-centred and value-driven care, it presents an opportunity to delve deeper into patients’ journey.
Our HF workgroup aims to implement a series of initiatives targeting pre-admission (HF - Extended Diagnostic and Treatment Unit (EDTU)) and post-discharge phases (HF Shared Care (HFSC) and Medical Home (MH)) of the patient’s journey, supporting their health needs in the community, thus reducing avoidable hospital readmissions.
Foremost, the team mapped out the patients’ journey and adopted a multi-pronged approach to i) manage mild HF patients presented to Emergency Department (ED) under HF-EDTU protocol and support ii) stable HF patients with co-morbidities (HFSC programme) and mild-to-moderately decompensated HF patients (MH programme) in the community.
Under HF-EDTU protocol (commenced Mar’ 22), brainstorming sessions were conducted with ED to determine the inclusion criteria to ensure safe discharge from ED. For HFSC programme (commenced Jul’ 22), we engaged Shared Care Partnership Office (SCPO) to partner General Practitioners (GPs) to co-manage stable HF patients with co-morbidities in the community. GP focus group discussions were held to gather inputs for effective implementation of HFSC programme. We also worked with Population Health and Community Transformation (PHCT) team to identify patients with haemodynamically stable medical conditions for MH programme (commenced Jun’ 22) to reduce unnecessary hospitalisation. Regular meetings were conducted to monitor and evaluate the progress of our initiatives.
Collectively, these initiatives contributed to a decrease in 30D readmission rate from 8.4% to 6.8% (≈19% relative reduction) and a decrease in total bill size from $4,847 to $4,802, when comparing across the pre (Apr 2021 – Mar 2022) and post-implementation of initiatives (Apr 2022 onwards).
To date, of the 11 HF-EDTU patients, 5 were discharged from EDTU, avoiding inpatient admission. This resulted in estimated cost savings of $7,595. Separately, 5 patients were enrolled into HFSC programme.
By adopting a strong value-driven methodology, we were able to assess and identify gaps in existing processes to create more value for our patients. Despite the short period of implementation, the drop in 30D readmission rate is testament to better and safer quality of care received by our patients. By working closely with private primary care providers, patients are able to embark on a lifelong relationship with their GPs to manage different aspects of their health (including preventive care). This is crucial as we tackle the wave of an ageing population and the rising impact of multiple chronic diseases.
With the current promising results, continuous Plan-Do-Study-Act cycles will refine and improve the uptake of our initiatives. Lastly, measurement of patient experience outcomes are underway to truly understand what matters to patients in their care journey.
Aims
We investigated titration patterns of angiotensin‐converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) and beta‐blockers, quality of life (QoL) over 6 months, and associated ...1 year outcome all‐cause mortality/heart failure (HF) hospitalization in a real‐world population with HF with reduced ejection fraction (HFrEF).
Methods and results
Participants with HFrEF (left ventricular ejection fraction <40%) from a prospective multi‐centre study were examined for use and dose relative to guideline‐recommended maintenance dose (GRD) of ACEis/ARBs and beta‐blockers at baseline and 6 months. ‘Stay low’ was defined as <50% GRD at both time points, ‘stay high’ as ≥50% GRD, and ‘up‐titrate’ and ‘down‐titrate’ as dose trajectories. Among 1110 patients (mean age 63 ± 13 years, 16% women, 26% New York Heart Association Class III/IV), 714 (64%) were multi‐ethnic Asians from Singapore and 396 were from New Zealand (mainly European ethnicity). Baseline use of either ACEis/ARBs or beta‐blockers was high (87%). Loop diuretic was prescribed in >80% of patients, mineralocorticoid receptor antagonist in about half of patients, and statins in >90% of patients. At baseline, only 11% and 9% received 100% GRD for each drug class, respectively, with about half (47%) achieving ≥50% GRD for ACEis/ARBs or beta‐blockers. At 6 months, a large majority remained in the ‘stay low’ category, one third remained in ‘stay high’, whereas 10–16% up‐titrated and 4–6% down‐titrated. Patients with lower (vs. higher) N‐terminal pro‐beta‐type natriuretic peptide levels were more likely to be up‐titrated or be in ‘stay high’ for ACEis/ARBs and beta‐blockers (P = 0.002). Ischaemic aetiology, prior HF hospitalization, and enrolment in Singapore (vs. New Zealand) were independently associated with higher odds of ‘staying low’ (all P < 0.005) for prescribed doses of ACEis/ARBs and beta‐blockers. Adjusted for inverse probability weighting, ≥100% GRD for ACEis/ARBs hazard ratio (HR) = 0.42; 95% confidence interval (CI) 0.24–0.73 and ≥50% GRD for beta‐blockers (HR = 0.58; 95% CI 0.37–0.90) (vs. Nil) were associated with lower hazards for 1 year composite outcome. Country of enrolment did not modify the associations of dose categories with 1 year composite outcome. Higher medication doses were associated with greater improvements in QoL.
Conclusions
Although HF medication use at baseline was high, most patients did not have these medications up‐titrated over 6 months. Multiple clinical factors were associated with changes in medication dosages. Further research is urgently needed to investigate the causes of lack of up‐titration of HF therapy (and its frequency), which could inform strategies for timely up‐titration of HF therapy based on clinical and biochemical parameters.
Aim
Different associations between epicardial adipose tissue (EAT) and cardiac function have been suggested in patients with heart failure with preserved (HFpEF) versus reduced and mildly reduced ...ejection fraction (HFrEF/HFmrEF). However, few studies have directly compared the association between EAT and left atrial (LA) and left ventricular (LV) function in patients with HFpEF and HFrEF/HFmrEF.
Methods and results
We studied EAT thickness using transthoracic echocardiography in a multicentre cohort of 149 community‐dwelling controls without heart failure, 99 patients with HFpEF, and 366 patients with HFrEF/HFmrEF. EAT thickness was averaged from parasternal long‐axis and short‐axis views, respectively, and off‐line speckle tracking analysis was performed to quantify LA and LV function. Data were validated in an independent cohort of 626 controls, 243 patients with HFpEF, and 180 patients with HFrEF/HFmrEF. For LV function, LV global longitudinal strain (GLS) was measured in both derivation and validation cohorts. For LA function, LAGLS at reservoir, contractile and conduit phase were measured in the derivation cohort, and only LAGLS at reservoir phase was measured in the validation cohort. In the derivation cohort, EAT thickness was lower in HFrEF/HFmrEF (7.3 ± 2.5 mm) compared to HFpEF (8.3 ± 2.6 mm, p < 0.05) and controls (7.9 ± 1.8 mm, p < 0.05). Greater EAT thickness was associated with better LV and contractile LA function in HFrEF/HFmrEF, but not in HFpEF (p for interaction <0.05). These findings were confirmed in the validation cohort, where EAT thickness was lower in HFrEF/HFmrEF (6.7 ± 1.4 mm) compared to HFpEF (9.6 ± 2.8 mm; p < 0.05) and controls (7.7 ± 2.3 mm; p < 0.05). Greater EAT thickness was associated with better LV and reservoir LA function in patients with HFrEF/HFmrEF but worse LV and reservoir LA function in patients with HFpEF (p for interaction <0.05). Thickened EAT (EAT thickness >10 mm) was associated with LA dysfunction (LAGLS at reservoir phase <23%) in HFpEF, but not in HFrEF/HFmrEF.
Conclusion
Epicardial adipose tissue thickness is greater in patients with HFpEF than HFrEF/HFmrEF. Increased EAT thickness is associated with worse LA and LV function in HFpEF but the opposite in HFrEF/HFmrEF.
Intracoronary bolus of eptifibatide during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) has been shown to result in higher local platelet glycoprotein IIb/IIIa ...receptor occupancy with improved microvascular perfusion. It is unclear whether intracoronary administration of eptifibatide in a larger patient population results in favourable clinical outcomes. We evaluated the safety and efficacy of two regimens of intracoronary eptifibatide (bolus only versus bolus followed by intravenous infusion) in patients undergoing primary PCI for ST-elevation MI. They were divided into two groups: Group A (n=67) who received fixed-dose intracoronary eptifibatide bolus only and Group B (n=88) who received intracoronary bolus and continuous intravenous infusion of eptifibatide for 18 h. The preliminary findings from our registry showed that both regimens were associated with good angiographic outcomes, few bleeding events and low in-hospital major adverse cardiac events. A large prospective randomized, multi-centre trial is needed to confirm our observation.
Aim
Pathophysiological differences between patients with heart failure with preserved (HFpEF) and reduced (HFrEF) ejection fraction (EF) remain unclear. Therefore we used a phenomics approach, ...integrating selected proteomics data with patient characteristics and cardiac structural and functional parameters, to get insight into differential pathophysiological mechanisms and identify potential treatment targets.
Methods and results
We report data from a representative subcohort of the prospective Singapore Heart Failure Outcomes and Phenotypes (SHOP), including patients with HFrEF (EF <40%, n = 217), HFpEF (EF ≥50%, n = 213), and age‐ and sex‐matched controls without HF (n = 216). We measured 92 biomarkers using a proximity extension assay and assessed cardiac structure and function in all participants using echocardiography. We used multi‐block projection to latent structure analysis to integrate clinical, echocardiographic, and biomarker variables. Candidate biomarker targets were cross‐referenced with small‐molecule and drug databases. The total cohort had a median age of 65 years (interquartile range 60–71), and 50% were women. Protein profiles strongly discriminated patients with HFrEF (area under the curve AUC = 0.89) and HFpEF (AUC = 0.94) from controls. Phenomics analyses identified unique druggable inflammatory markers in HFpEF from the tumour necrosis factor receptor superfamily (TNFRSF), which were positively associated with hypertension, diabetes, and increased posterior and relative wall thickness. In HFrEF, interleukin (IL)‐8 and IL‐6 were possible targets related to lower EF and worsening renal function.
Conclusion
We identified pathophysiological mechanisms related to increased cardiac wall thickness parameters and potentially druggable inflammatory markers from the TNFRSF in HFpEF.
Study design and main study results. CA125, carbohydrate antigen 125; CTSL, cathepsin L; DKK1, Dickkopf‐related protein 1; HBEGF, heparin‐binding EGF‐like growth factor; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; IL6, interleukin‐6; IL6R, interleukin‐6 receptor; IL8, interleukin‐8; LV, left ventricular; NGF, neurotrophic growth factor; PlGF, placental growth factor; TNFRSF, tumour necrosis factor receptor superfamily.
Background Data comparing outcomes in heart failure (HF) across Asia are limited. We examined regional variation in mortality among patients with HF enrolled in the ASIAN-HF (Asian Sudden Cardiac ...Death in Heart Failure) registry with separate analyses for those with reduced ejection fraction (EF; <40%) versus preserved EF (≥50%). Methods and Results The ASIAN-HF registry is a prospective longitudinal study. Participants with symptomatic HF were recruited from 46 secondary care centers in 3 Asian regions: South Asia (India), Southeast Asia (Thailand, Malaysia, Philippines, Indonesia, Singapore), and Northeast Asia (South Korea, Japan, Taiwan, Hong Kong, China). Overall, 6480 patients aged >18 years with symptomatic HF were recruited (mean age: 61.6±13.3 years; 27% women; 81% with HF and reduced rEF). The primary outcome was 1-year all-cause mortality. Striking regional variations in baseline characteristics and outcomes were observed. Regardless of HF type, Southeast Asians had the highest burden of comorbidities, particularly diabetes mellitus and chronic kidney disease, despite being younger than Northeast Asian participants. One-year, crude, all-cause mortality for the whole population was 9.6%, higher in patients with HF and reduced EF (10.6%) than in those with HF and preserved EF (5.4%). One-year, all-cause mortality was significantly higher in Southeast Asian patients (13.0%), compared with South Asian (7.5%) and Northeast Asian patients (7.4%;
<0.001). Well-known predictors of death accounted for only 44.2% of the variation in risk of mortality. Conclusions This first multinational prospective study shows that the outcomes in Asian patients with both HF and reduced or preserved EF are poor overall and worst in Southeast Asian patients. Region-specific risk factors and gaps in guideline-directed therapy should be addressed to potentially improve outcomes. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01633398.
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