Pascal Poncelet

074 Is management of heart failure at hospital discharge differentiated according to the ejection fraction? Lessons from the DEVENIR study

Rationale Heart failure (HF) with preserved LVEF has been individualized in the recent years as a specific entity, with different mechanisms, special baseline characteristics, a poor prognosis and no clearly recognized treatment. Recent papers have focused on patients with LVEF between 40% and 50% who could not be clearly classified as patients with reduced or preserved LVEF. Objectives to describe the management care of patients according to the LVEF with special emphasis on patients belonging to the “grey zone”. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and have been hospitalised for HF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge. Results 412 French outhospital cardiologists included 1 452 patients meeting the inclusion criteria. Management care at hospital discharge according to LVEF (known in 1 408 patients) is detailed below. Conclusion This is the first French survey in patients managed by cardiologists after hospital discharge for HF. Cardiologists mainly care for patients with low LVEF. Treatment at hospital discharge is optimal regarding medical classes, with poor differences according to EF. Rate of betablockers and ACEI is quite high in the group with EF > 50%, even if it is lower than in the groups with low EF. As a whole, in France, the 40-50% group is managed as the Table. Drug therapy according to LVEF LVEF LVEF 40-50% n=366 LVEF>50% n=250 p ACEI/ARB 91% 90% † 83% 0,002 Betablocker 78% 76% † 64% Loop diuretics 90% 83% * 82% Spironolactone 29% 19% * 21% 0,0003 Digoxin 16% 15% 21% 0,15 Calcium antagonists 9% 18% †* 27% Anticoagulants 43% 41% 43% 0,64 p by ANOVA with Bonferroni correction; † p 50%; * p

089 Heart Failure management in ambulatory care: what happens beyond hospital discharge? Results from the DEVENIR study

Rationale Heart failure (HF) treatment is often started during hospitalisation and patients are generally taken over after discharge by outhospital cardiologists. Objectives To describe changes in HF treatment implemented by the outhospital cardiologist after hospital discharge. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and hospitalized for HF within the previous 18 months. Results 1 452 patients were included by 412 French outhospital cardiologists. 1170 have had at least one visit by the cardiologist between hospital discharge (mean delay 5.76±4.51 months). At hospital discharge, target doses were reached in 10.5% of patients receiving betablockers, 50.9% of patients with ACEI and in 4.1% of patients with ARB. Doses were increased in 25.3% of patients receiving betablockers, in 11.7% of patients receiving ACEI and in 10.3% of patients treated with ARB enabling a target dose in 20.4% of patients with betablockers, and in 83.2% of patients with ACEI or an ARB. Table. Evolution of treatment after discharge At hospital discharge At start of the survey Medication prescribed after discharge Medication discontinued after discharge Betablocker 826 (70,6%) 863 (73,8%) 87 (25,3%) * 50 (6,1%) * ACEI †† 807 (69,0%) 788 (67,4%) 46 (12,7%) * 65 (8,1%) ** ARB ‡ 170 (14,5%) 210 (18,0%) 56 (5,6%) * 16 (9,4%) ** ACEI or ARB 961 (82,1%) 973 (83,2%) - - * percentages calculated on the number of patients without the treatment at hospital discharge; ** percentages calculated on the number of patients without the treatment at hospital discharge; metoprolol, nebivolol, bisoprolol, carvedilol; †† captopril, enalapril, lisinopril, trandolapril, ramipril, perindopril (at an accepted target dose of 4mg); ‡ candesartan, valsartan Conclusion Outhospital cardiologists play a critical role in care management of HF patients. Not only do they implement but they also amplify the care strategies defined during hospitalisation.

085 Therapeutic management of heart failure by french outhospital cardiologists is in line with ESH guidelines

Rationale HF treatment is often started during hospitalisation. It appeared interesting to describe the evolution of treatment after hospital discharge. Objectives To describe changes in HF treatment since hospital discharge after stratification on the time elapsed between discharge and beginning of the survey. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and have been hospitalised for HF within the previous 18 months. Results 1452 HF patients met the inclusion criteria and started the survey. 1170 (67% males, age 72±11 years, LVEF 40%±13%) have had at least one visit by the cardiologist between hospital discharge and entry in the survey. Patients were stratified according to the time since hospital discharge ( Conclusion Treatment strategies for Heart Failure started at hospital are well followed and amplified by French outhospital cardiologists after hospital discharge.

088 - Prescription of beta blockers at hospital discharge and beyond, in patients with heart failure. Results from the DEVENIR study

Rationale Beta blockers are a corner stone treatment of heart failure (HF) in patients with altered systolic function (LVEF 50%) or for patients belonging to the “grey zone” (LVEF 40-50%). Objectives to describe the prescription rate of beta-blockers in HF patients. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge. Results 1 452 patients were included by 412 French outhospital cardiologists. 1137 with known LVEF at hospital discharge have had at least one visit by the cardiologist between hospital discharge (mean delay 5.76±4.51 months). In a multivariate model, BB prescription was more frequent in HF from ischemic origin (OR=1.39) or with dilated cardiomyopathy (OR=1.44) and less frequent in older patients (OR=0.97 per year) and in case of asthma/COPD (OR=0.31 and if FEVG was >50% (OR=0.62). LVEF LVEF 40-50% N=282 LVEF > 50% N=194 Total N=1137 At hospital discharge/ at entry in the survey BB 78%/ 83% 78%/ 85% 62%/ 70% 76%/ 82% Recommended BB † 75%/ 77% 72%/ 74% 54%/ 62% 71%/ 74% Reaching the target dose 8%/ 16% 7%/ 16% 7%/ 13% 7%/ 15% Changes since discharge BB added * 28% 34% 25% 28% BB stopped ** 1% 1% 2% 1% BB dose increased * 27% 27% 17% 25% BB dose decreased 4% 1% 3% 3% † metoprolol, nebivolol, bisoprolol, carvedilol ; * percentage calculated in patients without BB at hospital discharge (N=278); ** percentage calculated in patients with BB at hospital discharge (N=859). Conclusion Rate of betablockers prescription is high at hospital discharge. Outhospital cardiologists not only pursue but also amplify the care strategies defined during hospitalisation increasing the proportion of patients receiving BB and the percentage reaching the target dose.

092 “Grey Zone” of 40-50% ejection fraction in ambulatory patient with Heart Failure. Who are these patients? Lessons from the DEVENIR study

Rationale Heart Failure (HF) with preserved LVEF has been individualized in recent years as a specific entity, with different mechanisms, special baseline characteristics, a poor prognosis and no clearly recognized treatment. LVEF cut-off has not been clearly defined. If 50% is generally accepted as a rather specific cut-off, there remains a « grey zone » of patients with EF between 40% and 50% not clearly individualized between reduced and preserved LVEF. Objectives to describe the characteristics of patients with LVEF belonging to the “grey zone” and to compare these patients to those with either reduced or preserved LVEF. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and have been hospitalized for HF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge. Results 412 French outhospital cardiologists included 1 452 patients with the inclusion criteria. Conclusion This is the first French survey in patients managed by cardiologists after hospital discharge for HF. Cardiologists mainly care for patients with low LVEF. Overall, the profile of patients with LVEF 40-50% at hospital discharge is closer to the 50% LVEF group. Characteristics according to LVEF at discharge (n=1 408) are displayed below. Table. Patients characteristics according to EF LVEF 50% n=250 P Age 71±12 73±11† 76±11 0,0001 Men 74% 65% 47% 0,0001 Ischemic etiology 53% 55%†,* 42% 0,003 Hypertensive etiology 30% 51%† 64% <0,0001 Valvular etiology 12% 17%†,* 25% <0,0001 Dilated cardiomyopathy 44% 25%†,* 8% <0,0001 Renal dysfunction 37% 34%† 27% 0,01 Sinus rhythm 71% 69%† 60% 0,008 Discharge BNP (pg/ml) 439 325 320 0,01 DischargeNYHA class III-IV 41% 29%†,* 21% <0,0001 p by ANOVA with Bonferroni correction; † p 50%; * p<0,05 for comparisons between “grey zone” and LVEF<40%. Comparisons for age adjusted for sex. Full-size table Table options View in workspace Download as CSV