Clinical InvestigationsManagement of heart failure in cardiac amyloidosis using an ambulatory diuresis clinic
Section snippets
Setting
The Johns Hopkins Heart Failure Bridge Clinic (HFBC) is a multidisciplinary HF disease management clinic.10 Chronic HF patients and those with mild HF decompensation are seen by HF-certified nurse practitioners for titration of oral HF medications, administration of IV diuretics, laboratory assessment, patient and caregiver education, and outpatient care coordination (Figure 1). A multidisciplinary team composed of advanced HF physicians, pharmacists, palliative care specialists, nutritionist,
Baseline Characteristics
There were 44 patients with CA included seen in the HFBC: 17 (39%) had AL-CA and 27 (61%) had ATTR-CA (13 [48%] with variant ATTR). The baseline characteristics are presented in Table 1. The cohort was predominantly male (n = 33, 75%), with a mean age of 71.3 ± 9.7 years, and NYHA Class III symptoms (n = 30, 68%). CA was most commonly diagnosed with endomyocardial biopsy (n = 36, 82%). In the 5 AL patients who were diagnosed with noncardiac tissue biopsy, all had multiple myeloma with amyloid
Discussion
We found that establishing care with a HF disease management clinic was associated with a reduced number of ED and inpatient visits, associated charges, and the proportion of days hospitalized in patients with CA. Furthermore, administration of IV diuretics in the outpatient setting was a safe alternative to hospitalization in our patient cohort. This is the first study of an ambulatory diuresis clinic to manage HF in patients with CA, a patient population with challenging HF physiology, low
Limitations
This study has several limitations. First, it is a single center study at a tertiary referral center for amyloidosis, therefore generalizability may be limited. Additionally, there is an inherent selection bias towards patients that completed at least one visit in the clinic. Second, the sample size was small, however given that CA is considered a rare disease, this is one of the largest cohorts to be reported, and the first description of ambulatory IV diuresis in this patient population.
Conclusion
In the modern era of CA, with an expected increase in prevalence and survival, effective strategies to manage congestion related to HF are critical. This is the first study of use of an ambulatory diuresis clinic in the management of HF related to CA. Our findings demonstrate the feasibility of outpatient administration of IV diuretics in a challenging patient population prone to HF hospitalizations. Our findings also suggest that close follow-up in a HF disease management clinic may reduce
Conflicts of Interest
None.
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Cited by (10)
Advances in the diagnosis and treatment of transthyretin amyloid cardiomyopathy
2024, Progress in Cardiovascular DiseasesPharmacological Management of Transthyretin Cardiac Amyloidosis
2023, Journal for Nurse PractitionersCitation Excerpt :Therefore, caution and appropriate monitoring must be employed.4 A retrospective study that examined the use of intravenous loop diuretics in an ambulatory diuresis clinic for ATTR-CA found that drugs such as furosemide are effective in symptom management, as evidenced by a reduction in emergency department visits and hospital admissions over the course of the study (P < .001, n = 27).9 Although furosemide was used in the ambulatory diuresis clinic study, torsemide or bumetanide are preferred in ATTR due to their greater bioavailability.8,10
“We're all we got is each other”: Mixed-methods analysis of patient-caregiver dyads’ management of heart failure
2022, Heart and LungCitation Excerpt :The present study engaged a mixed-methods study design of patient-caregiver dyads. Participants were recruited from the Johns Hopkins Hospital Heart Failure Bridge Clinic, a HF disease management clinic providing multidisciplinary HF care, primarily during the transition from hospitalization to home or episodes of ambulatory worsening HF.20,21 A purposive sampling strategy was used to recruit dyads with a range of caregiving experiences including spousal and non-spousal care dyads and those with unique caregiving needs.
ATTR Amyloidosis: Current and Emerging Management Strategies: JACC: CardioOncology State-of-the-Art Review
2021, JACC: CardioOncologyCitation Excerpt :No participants experienced symptomatic hypotension or severe kidney injury. Subsequent to establishing care at the diuresis clinic, there was a significant decrease in emergency department visits and inpatient admissions (13). We have previously shown a strong association between diuretic dose and mortality in an ATTR-CA cohort independent from other prognostic factors (14).
Ambulatory management of cardiac amyloidosis
2021, American Heart JournalResponse to letter to the editor: “Ambulatory management of cardiac amyloidosis”
2021, American Heart Journal