FASTTRACK - Facilitated Access to Optimized Treatment and Clinical Follow-Up for Elderly Patients by the Internal Medicine Heart Failure Outpatient Clinic - a Randomized Multicenter Prospective Study

FASTTRACC - Facilitated AccesS To Optimized TReAtment and CliniCal follow-up for elderly patients by the internal medicine heart failure outpatient clinic - a randomized multicenter prospective study

1. Abbreviations

HF - heart failure, GDMT - guideline directed medical therapy, DAOH - days alive and out-of-hospital, CRT - cardiac resynchronisation therapy, ICD - implantable cardiac defibrillator, IM-HF - internal medicine heart failure outpatient clinic, DIM - department of internal medicine, POCUS - point-of-care ultrasound 2. Background

Heart failure (HF) among older patients (more than 70 years of age) is one of the most common causes for hospital admission and re-admission.1 It is not only associated with increased mortality exceeding most malignant diseases, but also with a great amount of suffering and low quality of life for the patient, with repeated hospitalizations and inability to perform activities of daily life. HF also exerts a substantial financial burden on the healthcare system mostly driven by the high-rate of re-hospitalizations that accounts for more than 70% of the total HF health care cost.2,3 Thirty-day readmission rates are reported to be as high as 22-25% 4,5 and mortality risk increases for each subsequent readmission.3 Most of these patients are elderly and burdened by several co-morbidities rendering them ineligible for advanced HF treatment such as device therapy (CRT/ICD) or mechanical support. Following hospital discharge, a majority of HF patients are referred to their primary care provider for clinical follow-up and treatment optimization.6 Due to lack of resources and an increasingly heavy burden placed on the primary care system, most of these patients don't receive their follow-up until 1-2 months after hospitalization for an acute episode of HF, at which time many have already been re-admitted to the hospital.7 This practice is not in line with current guidelines that recommend early and frequent follow-up after HF hospitalization following the STRONG-HF trial. STRONG-HF studied an intensive treatment strategy of rapid up-titration of guideline-directed medication therapy (GDMT) and close follow-up after an HF admission and showed reduced symptoms, improved quality of life, and reduced the risk of 180-day all-cause death or HF readmission compared with usual care.8,9 However, as impressive and powerful the effects of the STRONG-HF trial were; the mean age of study participants were 63 years and less than 1700 patients were included from 14 countries and 87 hospitals during more than four years. This can, of course, partly be explained by the COVID-19 pandemic but still raises the question of STRONG-HF's applicability in the everyday real-world clinical setting with an elderly HF-population with multiple co-morbidities who are unlikely to tolerate the aggressive strategy enlisted in STRONG-HF. This creates an evidentiary vacuum for the elderly HF-patients and their response to intensified GDMT that our study intends to fill.

Almost half of all HF re-admissions are estimated to be a result of suboptimal transitional care i.e., the vulnerable phase between discharge from the hospital and initiation and continuity of care in the outpatient setting.10,11