Start in ward, finish in community: in-hospital semaglutide with 30-day nurse titration for obesity-associated heart failure with preserved ejection fraction vs usual discharge care
F Khan, P R O F Fazal Akbar, D R Muhammad Waleed, D R Kamran AslamAbstract
Background
In obesity-associated heart failure with preserved ejection fraction (HFpEF), the usual failure mode after discharge is not lack of intent—it is delay. In our ward workflow, anti-obesity therapy was commonly deferred because early outpatient slots were scarce, travel barriers were real, and dose escalation rarely happened without a proactive contact plan.
Purpose
To test whether starting semaglutide during hospitalisation, then handing off titration to a structured 30-day nurse protocol, improves early health status versus usual discharge care.
Methods
Pragmatic prospective cohort design. Of 526 screened admissions, 412 eligible adults were enrolled (pathway n=218; usual care n=194). We chose a 30-day primary window because it matches the "vulnerable month" when congestion, adherence, and access problems cluster—and when a missed start often becomes a missed year. The pathway was offered when a trained nurse-titration slot and phone follow-up capacity were available at discharge; otherwise, patients received usual care. Semaglutide was selected for once-weekly dosing (simpler logistics during transition) and a predictable escalation schedule. Primary endpoint: change in Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) from discharge to day 30. Prespecified regression models adjusted for age, sex, body mass index, diabetes, atrial fibrillation, and baseline KCCQ-12.
Results
Thirty-day KCCQ-12 was obtained in 365/412 (88.6%). Semaglutide initiation before discharge occurred in 210/218 (96.3%) in the pathway group. Mean KCCQ-12 change was 20.0 (SD 8.9) with the pathway versus 10.0 (SD 9.7) with usual care (adjusted difference 10.0 points, 95% CI 7.6–12.4; P<0.001). Weight change was −5.4 (SD 3.0) kg versus −1.5 (SD 2.7) kg (adjusted difference −4.0 kg, 95% CI −4.6 to −3.4; P<0.001); ≥5% weight loss occurred in 113/195 (57.9%) versus 19/170 (11.2%). Thirty-day readmission occurred in 16/218 (7.3%) versus 27/194 (13.9%) (adjusted OR 0.51, 95% CI 0.26–0.99). Among initiators, discontinuation by day 30 was uncommon (11/210 [5.2%] vs 3/49 [6.1%]).
Conclusion
Starting semaglutide in hospital and owning the first month with nurse titration produced a larger early health-status gain and greater short-term weight reduction than usual discharge care. Here’s the trade-off: it front-loads work into discharge week and the first 30 days, but it avoids the more common—and costly—alternative of delayed initiation and stalled escalation.