Post Discharge Management of Heart Failure Patients: Clinical findings at the first medical visit in a single-center study

doi:10.21203/rs.3.rs-1655766/v1

Background. The Post Discharge Management of patients with heart failure impact significantly their incomes. This study aims to analyze the clinical findings and management at the first medical visit of these patients in our context.

Material and methods: This is a retrospective cross-sectional descriptive study on consecutive files of patients hospitalized for heart failure from January to December 2018 in our Department. We analyse data from the first post discharge medical visit. including medical visit time, clinical conditions and management.

Results: Three hundred and eight patients (mean age: 53.4 ± 17.0 years, 60% males) were hospitalized on median duration of 4 days [1-22 days]. One hundred and fifty-three patients (49,67%) were presented at the first medical visit after 60 days on average, 10 (3.24%) patients died before this first medical visit and 145 (47.07%) had been lost to follow-up. The re-hospitalization and treatment non-compliance rates were 9.4% and 3.6%, respectively. Male gender (p = 0.048), renal failure (p = 0.010), and Vitamin K antagonist (VKA) /direct oral anticoagulant (DOAC) (p = 0.049) were the main lost to follow-up factors. Hyponatremia (37%), tachycardia (28%) and LVEF <25% (12%) were the major factors of poor prognosis.

Conclusion: The management of patients with heart failure after discharge from hospital seems to be insufficient and inadequate. A specialized unit is required to optimize this management.

Heart failure

Postdischarge

Management

The transition period from the start of hospitalization of patients with heart failure to a period around discharge from hospital and up to 6 months after is called the "vulnerable phase", during which the patient is at high risk of adverse events due to multiple cardiac and non-cardiac factors [1, 2] with post-hospital mortality rates of up to 15% and readmission rates of 20% to 30% in the first 30 days after discharge from hospital [3]. Thereby, the post-hospitalization management of patients with heart failure is crucial and raises 4 issues: 1- the time of the first post-hospitalization consultation, 2- the patient's clinical condition at this first consultation, 3- the post-hospitalization therapeutic optimization, 4- improved prognosis with the issue of mortality and re-hospitalizations. According to the literature [4, 5], less than a third of patients hospitalized for heart failure saw a cardiologist within the first 3 months after discharge from hospital. Thus, in the United Kingdom for example, only 56% of hospitalized patients had an organized follow-up [6]. This poor coordination is one of the major reasons why the titration of essential drugs remains suboptimal and has a considerable impact on the prognosis of patients such that approximately 1 in 4 patients is readmitted within 30 days of hospitalization. and almost half within 6 months during this period called "vulnerable phase"; and 5% may die during this period [3, 7]. The most recent international guidelines recommend a follow-up visit within 7-14 days and / or a telephone follow-up within 3 days of hospital discharge [6,8,9]. However, data from several countries suggest that such early follow-up is exceptional [6]. Patients who overcome this period successfully can make the transition to long-term stability [1].

This study aims to analyze the management and outcomes of these patients immediately after hospitalization in our context.

This is a cross-sectional retrospective study covering all consecutive files of patients hospitalized in our Department between January 1st, 2018 and December 31st, 2018. The main diagnosis retained at the discharge was heart failure according to Framingham clinical criteria. An update of the data by telephone call including the evaluation of the prognosis of the patients was carried out from January 2019 to May 05, 2019. Were included in our study, all adult patients, hospitalized for heart failure, released alive from the hospital and whose clinical course was favorable. We analyzed the data from the first post-hospitalization consultation, namely the epidemiological, clinical, therapeutic and evolutionary aspects of these patients at this first consultation. The data was collected on an individual survey sheet, filled in according to the various parameters studied, based on the medical file. Statistical analysis was carried out using Epi info 7 software and using SPSS 27.0 software for Windows. The qualitative values were expressed as a percentage and the quantitative variables as the mean ± standard deviation. Comparisons were made with ANOVA for quantitative variables and the Chi2 test for qualitative variables. A p value <0.05 was considered statistically significant.

Epidemiology and clinical

We collected 308 files including 184 male patients and 124 female patients with a sex ratio M / F = 1.5. The mean age was 53.4 ± 17.0 years [range: 19 - 85 years]. The 60-69 age group was the largest. The clinical characteristics of the patients are listed in Table I. The mean weight of all patients was 63.7 ± 21.6 kg [range: 44 - 95 kg]. The average height was 1.73 ± 0.10 m [Extremes: 1.60 - 1.92 m]. The body mass index was estimated to be 29.55 ± 9.45 kg / m² [Extremes: 19.3 to 50.7 kg / m²]. Global heart failure was the most objective syndrome in hospitalization in over 72.1% (n = 222). Almost 52.92% of patients were at least at their 2nd episode of decompensation. Chronic decompensation (51.8%), PAO (28%) and low flow (13%) were the most frequent clinical forms. The most frequent aetiologies were dilated cardiomyopathies (56.5%), valve disease (15.4%) arterial hypertension (9.4%) which constituted more than two-thirds of the causes of heart failure. Decompensations factors were dominated by bronchopulmonary infections and poor adherence to therapy, respectively at 48.7% and 40.3%. The factors of poor prognosis were marked by hyponatremia (37%), tachycardia (28%) and LVEF <25% (12%) as shown in Figure 1. The electrocardiogram was performed systematically in all. the patients. Left ventricular hypertrophy was found in 33.8% of cases. The most common arrhythmia was complete atrial fibrillation arrhythmia (27.6%). Signs of myocardial ischemia were present in 18.5% of patients. Heart failure with altered ejection fraction constituted 77% of the total. The evolutionary and therapeutic data were variable as shown in Table II. The median length of hospitalization was 4 days [1-22 days]. Exit therapy consisted of diuretics in 93.2% of cases, beta blockers in 70.1% of cases and ACE inhibitors in 63.6% of cases.

Becoming patients after hospitalization

After leaving the hospital, the patients were seen for the 1st consultation. Their post-hospitalization status was assessed by analyzing their medical records and then updated by phone call. One hundred and fifty-three patients (49.67%) presented for the first post-hospitalization consultation. There were 10 deaths before the 1st consultation (3.24%) and 145 patients lost to follow-up at the 1st consultation (47.07%) as shown in Figure 2.

Number of consultations

During the study period, 65 patients (21.1%) had an average of 1 consultation, 51 patients (16.5%) had an average of 2 consultations, 17 patients (5.5%) had an average of 3 consultations, 7 patients (2.3%) had an average of 4 consultations, 4 patients (1.3%) had an average of 5 consultations, 1 patient (0.3%) had an average of 6 consultations.

Patients seen at the 1st consultation

Of 308 patients, 153 (49.7%) were seen at the 1st consultation. Regarding these patients followed, for a median expected time of 14 days, they were effectively reviewed after 60 days. Of these 153 patients, 29 (9.4%) had transited to the cardiological emergency department for rehospitalization (Table III).

Treatment

At this 1st consultation, the treatment of heart failure was increased; including doses of diuretics, beta blockers and ACE inhibitors (Figures 3-5). Were considered as low dose, medium dose and high dose of diuretics (Furosemide), respectively, the doses of diuretics (Furosemide) less than 80 mg / day, between 80 and 120 mg / day and between 120 and 250 mg / day. The low dose, medium dose and high dose of b-blockers (Nebivolol or Bisoprolol), respectively, were doses less than 2.5 mg / day, doses of between 2.5 and 7.4 mg / day and doses between 7.5 and 10 mg / day. The low dose, medium dose and high dose of converting enzyme inhibitors (Perindopril or Ramipril), respectively, were the doses less than 2.5 mg / day, the doses between 2.5 and 7.4 mg / d and doses between 7.5 and 10 mg / d.

Factors associated with loss of sight

Male gender (p = 0.048), renal failure (p = 0.010), and AOD AVK anticoagulation (p = 0.049) were factors associated with patients' vision loss (Table IV). However, after an update of the data by phone call, it turned out that ten patients (3.2%) died before the first consultation.

The patients in our series were relatively young with a mean age of 53.4 ± 17.0 years similarly to some authors reports [10, 11 - 17] unlike European and North American countries where patients hospitalized for heart failure are older with age. average varying between 66 - 74 years [18]. According to the age groups, the age group of 60-69 years was the most important in our series, unlike Cathy [19] in Canada in 2014 who reported the predominance of patients over 75 years in her series. This age difference seems to be probably explained by the etiologies of heart failure, life expectancy and standard of living. [20]. Indeed, although the relative percentage of heart failure caused by ischemic heart disease in sub-Saharan Africa is clearly increasing [21], arterial hypertension, dilated cardiomyopathy and rheumatic heart disease are the most common causes [10, 11, 22-24] and affect increasingly younger patients, while in Western countries, myocardial ischemia is the most common cause affecting much older patients [25]. As for sex, we noted a male predominance with a sex ratio of 1.5, while in the literature, the predominance can be male or female depending on the series [10].

Global heart failure was the most common clinical form (72.1% of cases) in patients hospitalized for heart failure, related to late admission of patients. Our results are comparable to those described by other authors who find values ranging from 66.4% to 88% [26-30]. Chronic decompensation, acute pulmonary edema and low cardiac output represented the most common clinical forms of heart failure in our hospitalized patients at respective proportions of 51.8%; 28%; and 13% unlike Ambrosy et al. in the United States of America in 2014 [18], which reported that low cardiac output was relatively rare in hospitalized patients with heart failure and the vast majority had signs of systemic congestion and hypertension. Decompensations factors were dominated by bronchopulmonary infections and poor adherence to therapy, respectively at 48.7% and 40.3%. These decompensation factors are clearly on the rise when compared to the results of Adoubi et al who carried out a study on a population almost comparable in 2010 [31] and who reported the infection, l renal failure and poor adherence to therapy in 39%, 33% and 24%, respectively, as factors in heart failure decompensation. Other African authors such as Benyass and Oyoo find bronchopulmonary infections as factors of decompensation in proportions of 32% and 17.6% respectively [27,32]. Most patients presented with impaired ejection fraction heart failure (77% of cases). Pio et al [26] in Togo in 2014, made the same observation, which found 88.6% of patients with heart failure with altered ejection fraction. The aetiologies of heart failure were strongly dominated in our series by dilated cardiomyopathies (56.5%), valve disease (15.4%) and arterial hypertension (9.4%). Like us, other authors such as Kingery [33], in Tanzania in 2017, kwan [34], in Rwanda in 2013 and Ogah [35], in Nigeria in 2014, reported these 3 main aetiologies but in proportions different. As for developed countries, ischemic and hypertensive heart disease are the most common causes of heart failure [36,37]. Hyponatremia (37%), tachycardia (28%) and LVEF <25% (12%) were the major factors of poor prognosis. This observation has also been made by several authors. Indeed, hyponatremia is one of the major biological factors of poor prognosis in heart failure [38-40], regardless of the use [39-41] and the dose of diuretics prescribed [40, 42]. In addition, tachycardia is described as a major factor of poor prognosis in patients with heart failure [40, 41] sometimes even linearly [40, 43, 44]. In addition, patients with preserved ejection fraction heart failure are reported to have a 4-10% greater chance of survival compared to those with reduced ejection fraction [40, 45-47]. The average length of hospitalization in our series was 6 +/- 5 days. Our data are similar to the results reported by certain authors such as Dang [48] in France in 2016, Butler [49], in the United States in 2012, Damasceno [50], in Mozambique in 2012 who respectively found an average duration of stay of 7.9 days (± 4.7); 5-10 days and 7 days, while others such as Steinberg [51] in the United States in 2012 found a shorter average duration of around 4 days. The bulk of the exit therapy in our series consisted of diuretics (93.2%), ACE inhibitors (63.6%), and beta blockers (70.1%). Our practice complied with the latest international recommendations, both American in 2017 [9, 52, 53] and European [54] in 2016, which recommend for the treatment of acute and chronic heart failure (HF) to favor diuretics, inhibitors converting enzyme and beta blockers. These recommendations are widely followed by practitioners [55-58]. Once discharged from hospitalization, the outpatient follow-up of patients with heart failure imposes several challenges to overcome: 1- the time to the first consultation, 2- treatment compliance, 3- prevention of readmissions. Of the 308 patients, 153 (49.67%) were seen at the 1st post-hospitalization consultation. Of these 153 received, 29 (9.4%) had passed through the cardiological emergency department with a view to their readmission in hospital. The patients followed (153) were actually seen again on average after 60 days. This average time to the 1st post-hospitalization consultation in our series was abnormally high compared to international standards. Indeed, international guidelines recommend that patients hospitalized for heart failure undergo a clinical examination by a clinician experienced in heart failure within 7 to 14 days post-hospitalization [8, 59-61]. The goal is to provide a high-quality transition to ambulatory and community care when possible. Ideally, patients should be enrolled in a structured multidisciplinary program [6]. The period of transition from hospital to ambulatory, according to the literature [1], is referred to as the "vulnerable phase" for hospitalized heart failure patients. Indeed, despite an apparent clinical and hemodynamic improvement; and due to multiple cardiac and non-cardiac factors, patients early in the post-hospitalization period often present with worsening signs and symptoms of congestion and marked deterioration in hemodynamic and renal function [3]. Some of these abnormalities have prognostic significance influencing early mortality and / or re-hospitalization. Therefore, a follow-up visit within 1 to 2 weeks is recommended [3]. This follow-up visit is an ideal opportunity to initiate or increase the titration of the medication [62].

The rate of therapeutic non-compliance at the 1st consultation was estimated at 3.6%. This rate of therapeutic non-compliance is comparable to that of 5.8% reported by Chioncel [2] in Romania in 2018. However, it is lower than those of Ambrosy [18] in 2014 and Jackevicius [63] in 2015 both in the USA who found 8.9% and 30% respectively. According to the World Health Organization (WHO), there are 5 categories multifactorial causes of the therapeutic non-compliance: socioeconomic factors, factors associated with the health care team and system in place, disease-related factors, therapy-related factors, and patient-related factors [64]. Furthermore, the WHO supports that increasing the effectiveness of adherence interventions can have a much greater impact on the health of the population than any improvement in specific medical treatments [65]. Specifically, for patients with HF, several studies have shown that medication nonadherence was associated with an increased risk of mortality and readmissions [66-69]. Complex and independent factors affect treatment adherence. According to the WHO, these are factors linked to the health system, to the disease itself and its treatment, to the socio-economic status, and the level of education of the patient, to the patient-provider relationship, the fluctuating nature of HF, the acute and chronic nature of HF, and the patient's knowledge of their disease [70, 71]. Among the current interventions proposed to improve patient compliance after discharge from hospital, the one that appears to be the most relevant and effective is the initiation of medical treatment for heart failure in hospital [55, 72]. It was favorable to the first consultation after hospitalization in (86.8%), stationary in 9 (7%) and unfavorable 8 (6.3%) with re-hospitalization in 9.4% of cases. At this 1st consultation, the treatment of heart failure was increased, in particular the doses of diuretics, converting enzyme inhibitors and beta blockers as recommended by learned societies [53,54]. Post-hospital readmissions for heart failure are receiving special attention from researchers and policy makers, as they are seen as a correctable source of poor-quality care and excessive medical expenditure [73]. According to some authors such as Mirkin [74], male sex, black race, and co-morbidities (i.e., myocardial infarction, peripheral vascular disease, Chronic Obstructive Pulmonary Disease, diabetes, kidney disease, and moderate or severe liver disease) were associated. at a higher risk of post-hospital readmission for heart failure patients. Patient education, discharge planning, medication reconciliation, pre-discharge follow-up planning, communication with ambulatory care providers and jointly implemented follow-up phone calls helps reduce the risk of readmission within 30 days [75]. There is evidence that some strategies such as partnering with community physicians and health systems [76], better discharge summaries, and timely transmission of medical reports are associated with a lower risk of readmission for IC [77]. Overall, more support and careful outpatient monitoring have shown that readmissions can be avoided [78].

Of the patients lost to follow-up, one hundred and forty-five (47%) did not present at the first visit after hospitalizations. Male gender (p = 0.048), renal failure (p = 0.010), and VKA AOD anticoagulation (p = 0.049) were the factors associated with the patients' vision loss. However, after an update of the data by phone calls, it turned out that ten patients (3.2%) died before the first consultation and that the financial difficulties, the high financial cost of the medical services, the difficulties of displacement for patients, death, traditional therapy, naturotherapy, Chinese treatments, healing prayers, would explain the loss of sight of patients with heart failure after discharge from hospital. Also note especially the important deadlines for appointments. Some patients in this case prefer to be followed elsewhere. Apart from the study by Msadek [79] conducted in 2019 in France with general practitioners which alluded to the notion of lost to follow-up as an explanatory factor for the lack of post-hospitalization therapeutic optimization for heart failure, both African and Western studies on the issue of loss of sight in patients with heart failure in the post-hospitalization period seem to be almost non-existent.

Perspectives

These findings highlight the need for the training of a specialized and multidisciplinary unit to optimize the treatment of patients with cardiac insufficiency after discharge from the hospital, and the promotion of tele-consultation to improve the follow-up of these patients. This is a preliminary study that requires further, more in-depth studies and which, despite its limitations linked to the retrospective and monocentric nature, the large number of lost to follow-up retains all its originality.

Limitations

The limits of this study are linked to the retrospective and monocentric nature and the large number of lost to follow-up.

At the end of this study, our observation is that the time taken for the first consultation of these patients after discharge from the hospital is abnormally long the management seems to be insufficient and inadequate. Therefore, it is important to recognize that the management of this chronic condition follows a continuum, and that post-hospital treatment and follow-up are as important as hospital care. Better overall organization of medical care centered on patients with heart failure is therefore essential and requires a specialized unit to optimize treatment. Thus, a pharmaco-economic evaluation of new initiatives would be carried out to select the optimal strategies. In addition, seeing these patients again, preferably before 2 weeks after hospitalization, could help avoid a significant risk of death.

Acknowledgements

We kindly acknowledge those who participated in this research.

Author contributions

SF and AA contributed to the conception or design of the work. AKJB and AA contributed to the review of the article. All authors read and approved final of the manuscript.

Funding

None.

Availability of data and materials

“The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.”.

Ethics approval and consent to participate

The current study was approved by the Ethics Committee of the Abidjan Heart Institute Ethic board committee as ID: AKJB/GK N°014-2021/MSHP/ICA/DG/DMS. All methods were performed in accordance with the 1964 Helsinki Declaration. Informed consent was obtained from the participants.

Consent for publication

Not applicable.

Competing interests

The authors in this study declare no conflict of interest.

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Table I: Characteristics of patients hospitalized for heart failure

Characteristics	N = 308
Average weight (kg) ± standard deviation	63.7 ± 21.6
Average height (m) ± standard deviation	1.7300 ± 0.10374
Average BMI (kg / m²) ± standard deviation	29.556 ± 9.45
Type of heart failure; n (%)	N = 308
Right	48 (15.6)
Left	91 (29.6)
Global	169(54.8)
Nth episode of decompensations; n (%)*	N=308
1st episode	145 (47.08)
2nd episode	115 (37.33)
3rd episode	31 (10.06)
4th episode	9 (3.00)
5th episode	4 (1.30)
6th episode	3 (1.00)
8th episode	1 (0.32)
Forms of heart failure; n (%)
Chronic decompensation	100 (51.8)
Acute Lung Edema	54 (28)
Low flow	25 (13)
Hyperflow	6 (3.1)
Acute right heart failure	4 (2.1)
Others	4 (2.1)
Cardiogenic shock	0
Etiologies; n (%)	N=308
Dilated cardiomyopathy	174 (56.5)
Valvulopathy	48 (15.4)
Hypertention	29 (9.4)
Ischemic cardiomyopathy	27 (8.8)
Others	20 (6.5)
Chronic decompensation	5 (1.6)
Hypertrophic cardiomyopathy	4 (1.3)
Myocarditis	1 (0.3)
Aortic dissection	0
Severe rhythm disturbance	0
Tamponade	0
Decompensation factors; n (%)
Bronchopulmonary infections	150 (48.7)
Poor observance	124 (40.3)
Others	88(28.57)
Hydro soda overload	81 (26.3)
Renal dysfunction	76 (24.7)
Atrial fibrillation	54 (17.5)
Anemia	51 (16.6)
Pulmonary embolism	22 (7.1)
Ischemic	12 (3.9)
Bradycardia	3 (1)
Surgery	2 (0.6)
Alcohol and drugs	2 (0.6)
Asthma	2 (0.6)
Hyperthyroidism	1 (0.3)
Infectious endocarditis	1 (0.3)
Electrocardiographic aspects; n (%)
Sinus rhythm 72.4%	223 (72.4)
Left ventricular hypertrophy	104 (33.8)
Atrial fibrillation 27.6%	85 (27.6)
Ischemia	57 (18.5)
Echocardiographic aspects; n (%)
Altered Ejection fraction	237 (77)
Preserved Ejection fraction	71 (23)

BMI: body mass index; * Nth episode of heart failure presented by patient at current admission

Table II: Hospital stay and treatment of patients hospitalized for heart failure

Characteristics	Values
Average length of hospital stay ± standard deviation (days)	6 ± 5
Exit processing; n (%)
Loop diuretics (Furosemide)	283 (93.2)
Strong diuretics (Furosemide ≥ 250 mg)	25 (8.1)
Nitrogen derivatives	7 (2.3)
Converting enzyme inhibitors	196 (63.6)
Central antihypertensives	4 (1.2)
Renin-Angiotensin System Inhibitors	25 (8.1)
B-blocker	216 (70.1)
Ivabradine	1 (3.2)
Calcium channel blockers	39 (12.7)
Aspirin	54 (17.6)
Aldactone	147 (47.7)
Digoxin	18 (5.8)
Anti-Vitamin K	64 (20.8)
Favorable evolution	308 (100)

Table III. Characteristics of patients at the 1st post-hospitalization consultation

Characteristics	Values
Seen in 1st consultation	153 (49.7)
Average consultation time (days) [extremes]	66.53 [0.06-369]
Hospital readmission	29 (9.4)
Clinical evolution at the 1st consultation	N=153
Favorable	136 (88.9)
Stationary	9 (5.9)
Unfavorable	8 (5.2)
Clinical state	N=153
Normal	101 (66.01)
Global heart failure	22 (14.4)
Chronic decompensation	11 (7.2)
Left heart failure	8 (5.2)
Right heart failure	6 (3.9)
Low flow	3 (2.0)
acute lung edema	2 (1.3)
Hyperflow	0
Cardiogenic shock	0

Table IV: Factors Associated with Vision Loss in Patients with Heart Failure

Variables	Follow-up n=163	Lost to follow-up n=145	p-value
Gender			0.048
M	90(48.9%)	94(51.1%)	0.048
Origin			0.468
Abidjan	105(75.5%)	102(76.7%)	0.468
Nationality			0.553
Ivorian	135(82.8%)	120(82.8%)	0.553
1st episode of decompensation			0.263
Y	63(38.7%)	65(44.8%)	0.263
Atrial fibrillation			0.124
Y	50(30.7%)	35(24.1%)	0.124
Renal failure			0.010
Y	31(19.0%)	45(31.0%)	0.010
Anemia			0.439
Y	26(16.0%)	25(17.2%)	0.439
AVK-AOD anticoagulation			0.049
Y	40(24.5%)	24(16.6%)	0.049

Y : Yes ; M : Male

No competing interests reported.

Post Discharge Management of Heart Failure Patients: Clinical findings at the first medical visit in a single-center study

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