Remote management by allied HCP an option post-MI

Low-risk patients who have undergone revascularization following an acute myocardial infarction (MI) could potentially be managed with allied healthcare practitioner (HCP)-led remote intensive management (RIM), according to results of the Singapore-based IMMACULATE* trial.

“Among patients hospitalized for acute MI with predischarge NT-proBNP** concentration >300 pg/mL, RIM, consisting of frequent remote consultation and medication adjustment led by nurse practitioners, had similarly low safety events and achieved similar dose intensities of ACEis/ARBs*** and β-blockers but did not improve the indexed LVESV^# at 6 months compared with face-to-face cardiologist-led [standard of care (SoC)],” said the authors.

In this three-centre study, 301 patients (5.3 percent female) with a recent acute MI and NT-proBNP levels >300 pg/mL who were undergoing early revascularization were randomized 1:1 to receive allied HCP-led RIM (mean age 55.3 years) or cardiologist-led SoC (mean age 54.7 years). Patients in the SoC group received usual face-to-face care from their cardiologists. Those assigned to the RIM group underwent remote (telephone) consultations for 6 months (weekly for 2 months, then every 2 weeks) with nurse practitioners which included dose adjustments of their medications (β-blockers and ACEis/ARBs). Cardiac MRI was performed within 5–10 days of hospital admission and at 6 months.

At baseline, median NT-proBNP level was 807 and 819 pg/mL in the RIM and SoC groups, respectively, while mean indexed LVESV was 32.4 and 30.6 mL/m², respectively. Fifteen patients had left ventricular ejection fraction (LVEF) <40 percent, with mean baseline LVEF of 57.4 and 58.1 percent in the RIM and SoC groups, respectively.

The incidence of the primary safety endpoint ie, hospitalization for hypotension, bradycardia, hyperkalaemia, or acute kidney injury (AKI), was low, occurring in zero RIM and two SoC recipients (one incident each of hypotension and AKI; p=0.50). [JAMA Cardiol 2020;doi:10.1001/jamacardio.2020.6721]

Adverse event (AE) incidence was comparable between groups (23 and 22 AEs in the RIM and SoC groups, respectively), as was serious AEs (19 vs 24 events).

Indexed LVESV at 6 months did not significantly differ between patients in the RIM and SoC groups (mean 28.9 vs 29.7 mL/m²; adjusted mean difference, -0.80 mL/m²; p=0.51). At 6 months, LVEF and LV mass index also did not significantly differ between groups (adjusted mean difference, 0.40 percent; p=0.68 and adjusted mean difference, -2.07 g/m²; p=0.07, respectively), nor did reduction in NT-proBNP levels (absolute difference, 1.01; p=0.93).

At 6 months, dose intensity score did not significantly differ between patients assigned to RIM and SoC, be it for β-blockers (mean 3.03 vs 2.91; adjusted mean difference, 0.12; p=0.10) or ACEis/ARBs (mean 2.96 vs 2.77; adjusted mean difference, 0.19; p=0.07).

The authors noted that the 6-month cost of RIM was higher than that of SoC ($631 vs $176 per patient), though this was primarily due to the increased number of teleconsultations (mean 17.8 [RIM] vs 0 [SoC]).

“Telemedicine has enabled the transition from face-to-face care and is set to play a key role in the post-COVID-19 era,” said the authors.

“The limited window for ameliorating adverse post-MI remodelling presents itself as a unique opportunity for more cost-effective telemedicine deployment,” they said. This is in contrast to telemedicine management following heart failure “which requires potentially perpetual deployment of telemedicine services to prevent recurrent hospitalization over a patient’s health span.”

The population was relatively young, most had preserved LVEF, and underwent early revascularization, factors that could have led to the neutral primary outcome, they added.

Despite the low number of AEs with RIM, the authors recommended further research in a larger patient population, particularly among patients with a higher risk profile and reduced LVEF.