Intravenous diuretics for heart failure at home- are we delaying the inevitable?

Introduction

Hospitalisation for worsening heart failure (WHF) places a substantial strain on healthcare resources. Increasingly, WHF is being managed in community settings, either at home or in daycare facilities in an effort to reduce the burden on inpatient services1. Managing WHF at home can be appropriate in some cases—especially for patients already diagnosed and closely followed. But there have always been safety concerns regarding this practice, even though a UK pilot trial provided some reassurance regarding its short-term safety2.

Purpose

Test the hypothesis that management of WHF at home is as safe as inpatient care in the longer-term

Methods

Ninety-three patients with WHF for which they received IV diuretics were followed for up to 5 years, of whom 33 were managed at home and 60 were hospitalised. Baseline characteristics including demographics, New York Heart Association (NYHA), renal function, echocardiographic findings were documented. All-cause hospitalisation and mortality at 60 days, 1 year and all follow-up were recorded.

Results

Baseline characteristics of patients are summarised in Table 1. Patients treated at home or as inpatients had similar age (77 vs 76 years), proportion of women (33% v 45%), proportion in NYHA functional class III or worse (79% and 80%) and HFrEF (58% vs 65%), or at least moderately impaired left ventricular systolic function (39% and 55%). However, patients treated at home had worse renal function (eGFR- 41 [28,54] vs. 59 [34,79], p=0.008).

By 60 days, a higher mortality was observed in those managed at home (24 % vs 12%), a difference that persisted at 1 year (52% vs 17%) and for the duration of follow-up (79% vs 25%; log rank P-value =0.001). Hospitalisations were also higher (87% vs 48%, log rank P-value <0.001) [Figure 1].

In a multivariable Cox Regression model, treatment of WHF at home and eGFR were independent predictors of death. Standard inpatient care was associated with lower mortality (Exp (B) 0.38, 95% CI 0.173-0.824 , p=0.014). Higher eGFR was also associated with lower mortality (Exp(B) 0.98, 95% CI 0.967-0.999, p=0.043). Moreover, inpatient care and eGFR independently predicted lower risk of readmission [Inpatient care: Exp (B) 0.35, 95% CI 0.19-0.66, p<0.001; eGFR: Exp (B) 0.97, 95% CI 0.96 -0.99, p<0.001].

Conclusion

Treatment of HF at home with IV diuretics increases risk of readmission and mortality when compared with standard inpatient care. We urge caution for sites developing such services before a large multicentre randomized trial demonstrates safety and effectiveness of managing WHF patients at home.Kaplan meier curve