• Heart Failure
• Cardiology Clinical Trials

• Heart Failure
• Cardiology & Cardiovascular Medicine
• Cardiology Clinical Trials

The Nurse-led Intervention for Less Chronic Heart Failure study [NIL-CHF], a randomized controlled trial, has provided evidence that nurse-led care confers greater benefit to heart failure (HF) patients in terms of reduced time in emergency care and improved longer-term cardiac recovery. The results of this study were presented by Simon Stewart, MD, Baker IDI Heart & Diabetes Institute, Melbourne, Australia.

Prevention of chronic HF (CHF) has only recently been studied [Ledwidge M et al. JAMA 2013]. Nurseled care may have potential benefit in reducing hospital admissions due to CHF [Pearson S et al. Arch Intern Med 2006]. The NIL-CHF trial explored the influence of nurseled management of patients with cardiovascular disease or a history of CHF on hospital admissions for CHF and all-cause mortality over a mean follow-up of 4.3 years (range, 41 to 66 months). The study was designed to create and test a program of care that cost-effectively prevents the development of CHF in at-risk patients without CHF.

Patients aged 45 years or older who had been admitted with a diagnosis of any cardiovascular condition except CHF were enrolled in this single-center study. Patients with CHF, as confirmed using echocardiography, or those who were subsequently re-admitted within 35 days for treatment of CHF were excluded. The primary end point was being event free after admission or all-cause mortality. Heart function was assessed (recovered, stable, or worse) 3 years after admission using echocardiography. Hospitalization rate and length of stay, all episodes of HF, emergency care, and any related cardiovascular events were recorded.

Patients were blindly randomized into usual-care or nurse-led clinical management, as described previously (Figure 1) [Carrington MJ & Stewart S. Eur J Heart Fail 2010]. The interventions included short- to medium-term support outside of the hospital (6 months) or longer-term support after the index hospital stay (18 months and 3 years). Support included telephone coaching and home visits, which were arranged based on the patients' clinical stability and their risk profile.

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Figure 1.

Study Design

Reproduced from Carrington MJ and Stewart S. Bridging the gap in heart failure prevention: rationale and design of the Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) Study. Eur J Heart Fail 2010;12(1):82–88. With permission from John Wiley & Sons, Inc.

The study identified 5100 high-risk people with cardiovascular disease who had been discharged. Of these, 1059 were eligible for inclusion and 624 were randomized to usual post-discharge care (n=314) or nurse-led home- and clinic-based care (n=310). In total, 611 subjects (standard group, n=310; nurse-led group, n=301) were followed up with for a mean of 1561±240 and 1541±257 days, respectively.

The mean age of the cohort was 66±11 years, and the majority (71%) was male. Of the cohort, 62% were hypertensive; 70% were abdominally obese; 70% had coronary artery disease; 12.4% had asymptomatic left ventricular systolic dysfunction, 56% had asymptomatic HF with preserved ejection fraction, 13% had both cardiac conditions, and 18% had normal function; 83% were receiving antiplatelet therapy, 73% were receiving statin therapy, 71% were receiving angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker, and 52% were receiving β-blockers.

There were 2507 hospital episodes representing 9847 days. Excluding same-day and emergency procedures, there were 827 all-cause admissions and 7824 days of hospitalization (median, 4.0 days; interquartile range, 3.0 to 9.0 days). Cardiovascular-related events included heart disease (n=455), musculoskeletal disease (n=385, of which 178 patients had chest pain), other cardiovascular disease (n=72), peripheral arterial disease (n=64), stroke or transient ischemic attack (n=40), and diabetes (n=22).

At the 3-year time point, there was no significant difference between the nurse-led care group and the usual care group relative to de novo hospitalization for heart failure (p=0.53) or death from any cause (p=0.797; primary end point comparison, p=0.493). More NIL-CHF cases showed reversal and recovery with respect to baseline left ventricular hypertrophy versus normal (39% vs 25%; p=0.047), initial left ventricular systolic dysfunction or HF with preserved ejection fraction versus normal (23% vs 16%; p=0.063), or any cardiac condition versus normal (36% vs 25%; p=0.011; OR, 1.35; 95% CI, 1.04 to 1.76). The nurse-led care produced improvements in many hospitalization-related parameters; however, only the number of emergency hospitalizations reached statistical significance (Table 1).

Study limitations included the single-center design (albeit, an expert tertiary care center) and an open-label design. Nevertheless, the data show the promise of the nurse-led approach in the treatment of patients with CHF and support the further investigation of this strategy.

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