Key Points:
- HF patients frequently present to the ED for acute exacerbations, and the decision whether to discharge, observe, or admit these patients can be complex.
- The COACH trial randomized acute HF patients presenting to the ED to either a standardized clinical risk stratification algorithm (based on the EHMRG30-ST score) with associated rapid outpatient HF clinic or to standard of care.
- Patients receiving the intervention had reduced 30-day and 20-month composite death and non-elective cardiovascular hospitalizations.
Heart failure management represents a complex continuum of care, from ambulatory medication adjustment for mild exacerbations to critical care for cardiogenic shock. While numerous risk stratification algorithms have been developed to best determine the level of care a given HF patient may need, the utilization of these scores on a large scale to improve outcomes has not been rigorously examined. In a breaking presentation at the 2022 AHA Scientific Sessions today, Dr. Douglas Lee (University of Toronto) and his team presented their study: “A Patient-Risk Based Health System Intervention for Acute Heart Failure Care: The Comparison of Outcomes and Access to Care for Heart Failure,” or the COACH trial.
The COACH study (NCT02674438) was a prospective multi-center stepped wedge cluster randomized clinical trial conducted at 10 sites in Ontario, Canada which evaluated the effects of both a) the utilization of a clinical algorithm for prognostication and (2) post-discharge follow-up in the RAPID-HF clinic within 48-72 hours for patients presenting to the ED with HF. The validated Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk score was used as the clinical algorithm to determine the necessity of inpatient admission. The inclusion criteria comprised any adults presenting to an emergency department with acute heart failure; relevant exclusions included palliative patients (or those with a DNR), non-residents of the province, dialysis-dependence, and a BNP value not consistent with HF. A total of 5,452 patients were randomized to either the algorithm and follow-up or standard of care. The mean age was 78, and 45 % of patients were female.
There were two co-primary outcomes: 1) early: 30-day composite of time to death or non-elective cardiovascular hospitalization and 2) late: the same composite at 20 months. Patients receiving the intervention had a reduced risk of the composite outcome at both 30 days (HR 0.880, 95% CI 0.781-0.991; p=0.0360) and 20 months (HR 0.951, 95% CI 0.926-0.986; p=0.007). Secondary outcomes included 20-month CV and HF-related hospitalizations, both of which were also significantly reduced in the intervention arm (HR 0.84, 95% CI 0.76-0.94; p=0.001 and HR 0.80, 95% CI 0.65-0.98; p=0.028 respectively).
When discussing the clinical implications of the study at AHA, Dr. Lee stated: “Systematic use of the EHMRG30-ST, a point-of-care tool to support clinical decision-making, coupled with rapid outpatient follow-up, reduced the risk of death or cardiovascular hospitalizations within 30 days and 20 months. Implementation of this approach may lead to a pathway for early discharge from the hospital or emergency department and improved patient outcomes.”