June 8, 2023Open Access
Specialized heart failure clinics versus primary care: Extended registry-based follow-up of the NorthStar trial
Key Result
Follow-up in specialized heart failure clinics did not reduce HF hospitalization or cardiovascular death compared to primary care in optimized HFrEF patients (HR 0.96; 95% CI 0.82-1.12).
Study Design
Type
RCT (n=921)
Multicenter
Yes
Structured PICO
Does continued follow-up in a specialized HF clinic reduce the composite of HF hospitalization or cardiovascular death in medically optimized HFrEF patients compared to primary care?
P
Population
921 medically optimized patients with heart failure with reduced ejection fraction (HFrEF) enrolled in the NorthStar study, median age 69 years, 24.7% female.
I
Intervention
Continued follow-up in a specialized heart failure (HF) clinic after optimization of guideline-directed therapy
C
Comparator
Follow-up in primary care
O
Outcome
Composite of HF hospitalization or cardiovascular deathcomposite
In medically optimized HFrEF patients, continued follow-up in specialized HF clinics does not improve long-term clinical outcomes or medication adherence compared to primary care.
Main Result
Effect estimate: HR 0.96 (95% CI 0.82-1.12)
Absolute Event Rate: 69.8% vs 70.5%
Abstract
BACKGROUND: Whether continued follow-up in specialized heart failure (HF) clinics after optimization of guideline-directed therapy improves long-term outcomes in patients with HF with reduced ejection fraction (HFrEF) is unknown. METHODS AND RESULTS: 921 medically optimized HFrEF patients enrolled in the NorthStar study were randomly assigned to follow up in a specialized HF clinic or primary care and followed for 10 years using Danish nationwide registries. The primary outcome was a composite of HF hospitalization or cardiovascular death. We further assessed the 5-year adherence to prescribed neurohormonal blockade in 5-year survivors. At enrollment, the median age was 69 years, 24,7% were females, and the median NT-proBNP was 1139 pg/ml. During a median follow-up time of 4.1 (Q1-Q3 1.5-10.0) years, the primary outcome occurred in 321 patients (69.8%) randomized to follow-up in specialized HF clinics and 325 patients (70.5%) randomized to follow-up in primary care. The rate of the primary outcome, its individual components, and all-cause death did not differ between groups (primary outcome, hazard ratio 0.96 95% CI, 0.82-1.12; cardiovascular death, 1.00 0.81-1.24; HF hospitalization, 0.97 0.82-1.14; all-cause death, 1.00 0.83-1.20). In 5-year survivors (N = 660), the 5-year adherence did not differ between groups for angiotensin-converting enzyme inhibitors (p = 0.78), beta-blockers (p = 0.74), or mineralocorticoid receptor antagonists (p = 0.47). CONCLUSIONS: HFrEF patients on optimal medical therapy did not benefit from continued follow-up in a specialized HF clinic after initial optimization. Development and implementation of new monitoring strategies are needed.