Education and support programs improve long-term outcomes for high-risk cardiac patients

More than 30 percent of patients who suffer heart failure die within one year, but education and support programs have been shown to improve that statistic.

According to two studies presented at the American College of Cardiology's 56th Annual Scientific Session, education and support programs designed to care for high-risk cardiac patients with more direct interaction and guidance were successful in both reducing hospital visits and increasing heart failure patients' chances of long-term survival. ACC.07 is the premier cardiovascular medical meeting, bringing together cardiologists and cardiovascular specialists to further breakthroughs in cardiovascular medicine.

A Long-term Prospective Randomized Control Study Using Repetitive Education at 6 Month Intervals and Monitoring for Heart Failure Outpatients - The REMADHE Study (Presentation Number: 415-9)

Disease management programs (DMP) have become an increasingly prevalent approach to caring for patients with cardiovascular disease, and many have proven to be successful at reducing hospital admissions and emergency room visits. The REMADHE study - conducted by investigators from the University of Sao Paulo Medical School in Brazil - assessed whether a nurse-based disease management program could improve the long-term outcome of low-risk heart failure outpatients already under the care of a cardiologist. For the first time, the REMADHE study introduced the concept of repetitive education and monitoring into the management of heart failure.

In this randomized trial conducted between October 5, 1999 and January 18, 2005, researchers compared the long-term outcomes of patients who received standard medical care (n=113) to those also engaged in a nurse-based disease management program, consisting of six-month repetitive education and telephone monitoring (n=237). The primary endpoints were death or hospitalization and improvement in quality of life, and secondary endpoints included death of any cause, unplanned hospitalization due to any cause, unplanned emergency necessity, total days of hospitalization and number of days of each hospitalization.

According to the trial results, patients who were involved in the disease management program spent an average of nine fewer days in the hospital (11.2 days vs. 19.9 in the standard care-only group). The program also improved quality of life for trial patients by reducing time spent in the emergency room (1.32 vs. 0.79 visits on average) and the patient's need for emergency care (3.76 vs. 2.19 visits).

"As people begin to live longer with cardiovascular illnesses, there should become more long-term disease management efforts, and we expect that as these programs evolve, they will become more effective at helping patients manage their conditions," said Edimar A. Bocchi, M.D., of the University of Sao Paulo Medical School and lead investigator of this study. "The benefits obtained in this trial by repetitive education and close monitoring suggest that this program could be proposed on a broad scale to improve long-term survival and quality of life in not only heart failure patients, but also low risk patients. In the end, we found education to be just as important as drug therapy, or perhaps more improtant."

Dr. Bocchi will present this study on Tuesday, March 27, at 12:15 p.m. in Hall A.

The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH-study): A Head-to-Head Comparison of Two Non-pharmacological Interventions (Abstract 415-5)

While data from previous smaller, mostly single center, trials has shown that nurse-led heart failure programs are beneficial for heart failure patients, no head-to-head comparisons between different nurse-led disease management programs have been reported to date. The purpose of the Coordinating study evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial, conducted by researchers from the University Medical Center Groningen in The Netherlands, was to determine the effectiveness and feasibility of basic versus intensive nurse-led support programs in a large group of heart failure patients, in terms of time-to-hospitalization for heart failure or death, and the number of 'unfavorable days' (not alive or in-hospital).

In this randomized, controlled trial, 1,023 chronic heart failure (CHF) patients in 17 cardiology centers in The Netherlands were assigned to one of three treatment strategies during 18 months:

• Control treatment ('Care as usual', n=339): standard visits to a cardiologist; eight weeks after hospital admission for CHF, and then every six months.
• Basic education and counseling (n=340): standard management indicated above, plus education, telephone contacts and additional visits to heart failure nurse every three months in a heart failure clinic.
• Intensive education and counseling (n=344): in addition to basic education and counseling oulined above, involves home visits, monthly contacts with the heart failure nurse and multidisciplinary advice.

At baseline, 50 percent of patients were in NYHA class II disease, while the rest were NYHA class III-IV. Over the course of 18 months, 411 patients (40%) reached at least one of the primary endpoints: increase in time-to-hospitalization for heart failure or death, and decrease in the number of 'unfavorable days.' There was no difference in time-to-hospitalization between the control group and the two intervention groups, and the effect among the two intervention groups was nearly similar. There was a 15 percent reduction in the total number of 'unfavorable days' in the two intervention groups (33,731 and 34,268 days, respectively), when compared to the control group (39,960 days). This reduction was mainly due to a 15 percent decrease in all-cause mortality in the two intervention groups combined, compared to the control group. The overall number of days of hospitalizations for CHF was comparable.

"Data from the COACH study, which is the largest by far in its field to date, do not support the findings of previous smaller studies which suggest additional education and counseling in a nurse-led heart failure clinic, on top of treatment by a cardiologist, is effective in reducing hospitalization for every individual patient with heart failure," said Tiny Jaarsma, M.D., of the University Medical Center Groningen and lead investigator of this study. "However, these data did show that a close intensive nurse-led follow-up program can decrease mortality at the 'cost' of more hospitalizations."