CONGRESS ABSTRACT

Background: the first year after an admission for an Acute Heart Failure (AHF) is the most critical time with the highest incidence of deaths and hospital readmissions. To improve the first-year follow-up after discharge of patients admitted to our ICCU (Intensive Cardiac Care Unit) and Cardiology ward for AHF in accordance with international guidelines, the first of November 2022 was launched the DIMACC project (‘Dimissioni Accompagnate’, i.e. Accompanied Discharge).    Aim: to assess the feasibility and main results of the pilot phase of the DIMACC project.  Methods: The DIMACC project is a prospective quality improvement study in real-world practice. At discharge each patient receives a list of health targets to be achieved on blood pressure, heart rate and weight, blood test results, symptoms, lifestyles and adherence to cardiovascular therapy. The follow-up consists of a structured pathways of visits and tests along twelve months. Data on the achievement of health targets were collected by nurses during the follow-up visits. Results: From 1.11.22 to 30.4.23, 39 patients (51%) out of 79 admitted for AHF to the ICCU and Cardiology ward of Pio XI Hospital in Desio were included in the project: 3 patients (8%) died, 3 (8%) were lost to follow-up, and 33 (84%) were followed up for one year. The percentage of patients that achieved at 12 months the health objectives agreed on at discharge is shown in the Figure. There is a good adherence to drug treatments and an optimal symptoms’ control. The most critical issues were related to excessive water consumption (present in 69% of cases) and insufficient physical activity (present in 59% of cases). Conclusions: The structured 12-month follow-up is feasible for AHF patients and only a minority of patients did not complete the pathway of visits and tests. The attainment of health objectives ranged from 31% to 100%. On average each patient misses 1 every 4 health objectives. New strategies will be implemented to support the patients in reaching and maintaining the agreed-on health targets. Regular monitoring and measurements of patients’ achievements will allow to identify and offer support to more at-risk subjects.