Impact of a multidisciplinary heart failure management program in ambulatory patients with heart failure with reduced ejection fraction referred for advanced heart failure therapy
Authors: Puwanant S , Kittipibul V.K , Sinphurmsukskul S.S , Siwamoksatham S.S , Ariyachaipanich A.A , Krailak L.K , Nakviroj P.N , Boonbumrung N.B , Boonyaratavej S.B 
Published: November 2020

Abstract

Objectives
To assess 1-year outcomes of patients with heart failure with reduced ejection fraction (HF-rEF) who referred to a multidisciplinary heart failure (HF) clinic for advanced HF therapy.

Methods
We studied consecutive 312 ambulatory patients (mean age 51 years, 79% male) with HF-rEF (mean EF 23±8%) who were referred from cardiologists and cardiac surgeons to a multidisciplinary advanced HF clinic. The study patients were divided into 3 groups based on HF/transplant cardiologist evaluation. Group A consisted of 65 patients who were listed for heart transplant (HTx). Group B consisted of 157 patients who were considered as potential HTx candidates but who were too well to be listed for HTx. All patients in this group were not on optimal medical therapy (OMT) for HF-rEF at the time of evaluation. Group C consisted of 90 patients who were not suitable for HTx. Primary outcomes included HTx, left ventricular assist device (LVAD), or death. Outcomes were assessed at baseline and at 1 year after referral

Results
During the mean follow-up period of 9.6±4.1 months, 88 primary outcomes (28%) occurred (43 deaths (14%), 42 HTxs (14%) and 3 LVAD implants (1%)). Patients in group A, B, and C had a1-year survival of 91%, 90%, and 78%, respectively. At 1-year follow-up, 59%, 3%, and 0% in patients in group A, B, and C underwent HTx. The median waiting time for HTx was 5 months. At 1 year after referral, there was a 20%, 92%, and 63% reduction in HF admission in group A, B, and C, respectively; 44 HF admissions (0.2%/patients) occurred at 1 year after referral, compared with 530 HF admissions (1.7%/patients) 1 year before referral (p&lt;0.001). There was a significant increased rate of β-blocker (BB) use at 1 year (69% vs. 95% receiving BB, p&lt;0.001; and 5% vs. 43% receiving target dose of BB, p&lt;0.001). There was also an increased use of angiotensin converting enzyme inhibitor (ACE-I) /angiotensin receptor blocker (ARB)/ angiotensin receptor Neprilysin inhibitor (ARNI) (68% vs. 88% receiving ACE/ARB/ARNI, p&lt;0.01; and 6% vs. 17% achieving target dose, p&lt;0.01). The increase in utilization of BB and ACE/ARB/ARNI was evident across the 3 groups. LVEF recovery at 1 year occurred in 2%, 28%, and 6% in patients in group A, B, and C. Ten patients in group A (15%) were delisted for clinical improvement. Peak oxygen consumption improved after 1-year referral (13.9 vs. 19.5 ml/kg/min, p&lt;0.01).

Conclusions
In the contemporary treatment of HF, a multidisciplinary HF clinic led to improved optimal medical therapy (OMT), and an 88% reduction in HF admission in ambulatory patients with HF-rEF. The impact of these benefits was evident across the entire spectrum of HF severity particularly patients who were considered as potential HTx candidates but who were not on OMT (50% of referrals). About a third had LVEF recovery after intensive medical therapy. These findings suggested that OMT and intensive multidisciplinary HF care may prevent overtreatment HTtx.

Funding Acknowledgement
Type of funding source: None