Decreased hospitalization with point-of-care risk stratification and early follow-up for acute heart failure

Reference

Lee DS, Straus SE, Farkouh ME, et al, for the COACH Trial Investigators. Trial of an intervention to improve acute heart failure outcomes. N Engl J Med 2023;388(1):22-32.

Synopsis

In this study from Canada, investigators enrolled patients presenting to the emergency departments (EDs) of 10 hospitals with acute heart failure (HF). Patients with end-stage disease or those receiving palliative care were excluded. Hospitals were randomized to staggered start dates to cross over from a control phase to an intervention phase. Patients who presented during the control phase (n = 2972) received usual care. Those who presented during the intervention phase (n = 2480) were assessed using a clinical decision-making support strategy. With this strategy, clinicians had access to a validated point-of-care tool for risk stratification (EHMRG30-ST) of patients to low, intermediate, or high risk of death at 7 days and 30 days. Patients at low risk were recommended for early discharge, either directly from the ED or after a brief observation period of up to 3 days, followed by transitional care in a HF clinic for up to 30 days. Patients at high risk were recommended for admission to the hospital. Intermediate-risk patients were triaged based on clinical judgment (early discharge for low-to-intermediate risk, admission for intermediate-to-high risk). The intervention and control groups were balanced at baseline with mean age of 78 years and 45% female participants. Although both groups had a similar number of early discharges in low-risk patients, the intervention group had an increased rate of early discharges in the intermediate-risk group (51% vs 44%) and a decreased rate in the high-risk group (19% vs 27%). The primary outcome of all-cause death or non-elective hospitalization for cardiovascular causes was lower in the intervention group at 30 days (12.1% vs 14.5%; hazard ratio [HR] 0.88; 95% CI 0.78 - 0.99) and at 20 months (54.4% vs 56.2%; HR 0.95; 0.92 - 0.99). This was primarily driven by fewer cardiovascular hospitalizations in the intervention group (8.1% vs 10.6% at 30 days; HR 0.85; 0.74 - 0.98).