Bridging the vulnerable post-discharge window in acute heart failure: short and long term outcomes of a dedicated ambulatory advanced therapy center— a propensity score matched study

Abstract

Acute HF (AHF) hospitalization increases the risk for death and readmission, particularly when residual congestion exists at discharge. Although early initiation and rapid titration of guideline-directed medical therapy (GDMT) improve outcomes, timely dose optimization is challenging.

Aim

To evaluate the efficacy and safety of a multidisciplinary, dedicated ambulatory advanced HF therapy center (AHTC)- a high-intensity, protocol-driven transitional-care model providing education, close monitoring, intravenous diuresis, and rapid GDMT optimization—compared with standard post-AHF care.

Methods

We performed a retrospective cohort study of 9,451 adults discharged following hospitalization for acute heart failure (ADHF) between 2000 and 2025. The exposure of interest was attendance at the AHTC within 30 days of discharge.

Propensity scores were estimated using multivariable logistic regression incorporating age, sex, hypertension, ischemic heart disease, diabetes mellitus, atrial fibrillation, baseline estimated glomerular filtration rate (eGFR), guideline-directed medical therapy (GDMT) score, discharge heart failure pharmacotherapy, and furosemide dose. Patients attending AHTC were matched 1:2 to propensity score–matched controls using nearest-neighbor matching without replacement, yielding 92 AHTC-treated patients and 182 matched controls. The primary outcome was all-cause mortality. The prespecified renal safety composite included eGFR <15 mL/min/1.73 m², ≥50% decline in eGFR, initiation of renal replacement therapy, or hospitalization for renal or electrolyte-related complications.

Results

Among 92 AHTC-managed patients, the mean age was 72 years, 26% were women, and the mean LVEF was 46%, with 57% having LVEF ≥50%. Most patients were in NYHA class II–III (74%). Baseline NT-proBNP was 5,593 pg/mL (IQR 2,709–11,034) and mean eGFR was 47±23 mL/min/1.73 m², with no significant differences compared with matched controls. Thirty-day mortality was significantly lower in the AHTC group (2 deaths, 2.17%) compared with Standard of Care (22 deaths, 12.09%; P=0.006; Figure 1). Over 1 year of follow-up, patients attended a median of 9 (range 1–40) center visits. A total of 91 deaths occurred, with AHTC management associated with a significant reduction in all-cause mortality (HR 0.48, 95% CI 0.29–0.79; P=0.004; Figure 2). During follow-up, 24 of 92 AHTC-treated patients were hospitalized at least once. Median body weight decreased from 81.5 kg (IQR 68.5–93.5) at baseline to 76.5 kg (IQR 66.5–91.0) at 1 year (P=0.0019). SGLT2 inhibitor–specific GDMT scores improved over one year, and renal safety was preserved, with no significant between-group differences in renal outcomes

Summary

Center-based transitional care enabled faster decongestion and GDMT optimization without excess renal risk and provides a compelling rationale for validation in adequately powered, prospective randomized controlled trials.