Elsevier

American Heart Journal

Volume 233, March 2021, Pages 122-131
American Heart Journal

Clinical Investigations
Management of heart failure in cardiac amyloidosis using an ambulatory diuresis clinic

https://doi.org/10.1016/j.ahj.2020.12.009Get rights and content

Background

Recurrent congestion in cardiac amyloidosis (CA) remains a management challenge, often requiring high dose diuretics and frequent hospitalizations. Innovative outpatient strategies are needed to effectively manage heart failure (HF) in patients with CA. Ambulatory diuresis has not been well studied in restrictive cardiomyopathy. Therefore, we aimed to examine the outcomes of an ambulatory diuresis clinic in the management of congestion related to CA.

Methods and Results

We retrospectively studied patients with CA seen in an outpatient HF disease management clinic for (1) safety outcomes of ambulatory intravenous (IV) diuresis and (2) health care utilization. Forty-four patients with CA were seen in the clinic a total of 203 times over 6 months. Oral diuretics were titrated at 96 (47%) visits. IV diuretics were administered at 56 (28%) visits to 17 patients. There were no episodes of severe acute kidney injury or symptomatic hypotension. There was a significant decrease in emergency department and inpatient visits and associated charges after index visit to the clinic. The proportion of days hospitalized per 1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, P< .001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, P< .001) pre- vs post-index visit to the clinic.

Conclusions

We demonstrate the feasibility of ambulatory IV diuresis in patients with CA. Our findings also suggest that use of a HF disease management clinic may reduce acute care utilization in patients with CA. Leveraging multidisciplinary outpatient HF clinics may be an effective alternative to hospitalization in patients with HF due to CA, a population who otherwise carries a poor prognosis and contributes to high health care burden.

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.

References (28)

  • G. Gilstrap Lauren et al.

    Epidemiology of cardiac amyloidosis–associated heart failure hospitalizations among fee-for-service medicare beneficiaries in the United States

    Circulation

    (2019)
  • MA. Gertz

    Immunoglobulin light chain amyloidosis: 2020 update on diagnosis, prognosis, and treatment

    Am J Hematol

    (2020)
  • MS Maurer et al.

    Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy

    New Engl J Med

    (2018)
  • K Hebert et al.

    Open access to an outpatient intravenous diuresis program in a systolic heart failure disease management program

    Congest Heart Failure

    (2011)
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