Outpatient management of Heart Failure: from guidelines to clinical practice

Background: Heart Failure (HF) is a multi-faceted and life-threatening syndrome characterized by significant morbidity and mortality, poor functional capacity and quality of life, and high costs. Therefore, attempts to decrease its social and economic burden have become an important global public health priority. HF is frequently managed in internal medicine but after the acute phase subjects are mainly followed in outpatient cardiology settings. However, translating guideline recommendations for the management of this syndrome requires both a thorough understanding of the therapy and a long-term assessment on the prognosis of HF. Objectives: To describe baseline characteristics, pharmacological treatment and outcomes in outpatients with chronic HF discarged from an internal medicine ward, focusing on (i) 30-day readmission and (ii) all-cause mortality. Methods: This retrospective, single-center observational study included N=135 consecutive patients with chronic HF referred to a dedicated outpatient clinic from October 2017. Based on left ventricular ejection fraction (EF) patients were divided in those having reduced HF (HFrEF ≤40%, n=92), mild HF (HFmrEF, 41–49% n=12), and preserved HF (HFpEF, ≥50%, n=31). At baseline HF-specific therapy was started and the 30-day readmission was detected. All-cause mortality was assesed as a time-to-event outcome using Kaplan–Meier analysis, with estimation of cumulative mortality at 1, 3 and 5 years and censoring of alive patients at the last available outpatient follow-up visit. Results: The overall 30-day readmission rate was 9.6% and it was similar across the above-mentioned EF categories (i.e. 9.8%, 8.3% and 9.7%, respectively, NS). During the follow-up, 32 deaths occurred (23.7%). Overall mortality was higher in HFrEF (26/92, 28.3%) than in HFmrEF (2/12, 16.7%) and HFpEF (4/31, 12.9%, p<0.05 for trend) subjects, but Kaplan–Meier survival curves did not differ significantly across EF categories (log-rank p = 0.870). In Cox models, markers of global severity (notably older age and high NT-proBNP) provided the strongest prognostic value, whereas EF category showed weaker associations with mortality. Conclusions: In this real-world internal medicine outpatient allocated for the management of HF, a very low incidence of 30-day readmission (~10%) was observed. Long-term prognosis seems to be more closely related to global disease severity than to EF category alone, supporting that a structured follow-up and an individualized therapy optimization in multimorbid HF patients are needed.