Examination of the usefulness of our original clinical pathway for acute care of congestive heart failure aiming to improve short and long-term clinical prognosis

Background In August 2015, we introduced our own clinical pathway(PATH) that prescribes early oral administration of the powerful diuretic tolvaptan (approved for use in Japan) for congestive heart failure (CHF) cases, aiming for efficient acute treatment through early diuresis. PATH has been in use for nine years, with various revisions. In PATH, we also prescribe comprehensive lifestyle guidance by a multidisciplinary team to maintain good medical condition after discharge. Since the introduction of the pathway, the average length of hospitalization for CHF cases has been significantly shortened, and the rate of re-admission for heart failure after discharge has also significantly decreased. In recent years, an intravenous version of tolvaptan had also been released, and PATH is now being used in a wider range of CHF cases, including the cases unable to take oral medication. Purpose In this study, we re-examined whether the revised PATH is still useful in improving the clinical prognosis of CHF cases compared to before PATH was introduced. Methods Among patients who were first admitted to our hospital with CHF and discharged to home, we targeted 117 patients (N-group) who were admitted before the introduction of PATH (April 2014 to July 2015) and 197 patients (P-group) who were admitted in the last 2 years (August 2021 to July 2023) and applied PATH. We investigated the acute medical treatment status after hospitalization, average length of hospitalization, and clinical course after discharge for both groups, and examined the differences between the two groups. Results There were no differences between the two groups in mean age, other patient background, and clinical data at the time of admission. Acute phase treatment procedures were omitted more often in P-group, and in cases performed any acute treatment, its duration was significantly shortened in P-group. Cardiac rehabilitation was initiated early on in almost all cases in P-group, with physical therapy and occupational therapy (Figure 1). The mean length of hospital stay was significantly shorter in P-group, and the rate of rehospitalization due to CHF worsening within one year after discharge was lower in P-group (Figure 2). Conclusions Even now, nine years after the introduction of our original clinical pathway for acute care of congestive heart failure, its usefulness has been confirmed in improving short-term and long-term clinical course. This is likely due to the continued effectiveness of efficient medical care by early diuresis using oral and injected tolvaptan, and comprehensive lifestyle guidance after discharge provided by multidisciplinary staff.