Acute heart failure (AHF) is a common cause of hospitalization and is associated with high mortality rates, long hospital stays and high economic costs worldwide. Novel care pathways are increasingly being considered to address these burdens. FIL-EAS-ic a mixed French conventional hospitalization and hospital-at-home (HaH) care pathway, under the responsibility of a multidisciplinary HF hospital team managing the city-hospital transition has been designed to reduce the length of hospital stay without compromising HF outcomes for patients.

The primary objective of the study described in this protocol will be to evaluate the non-inferiority of the FIL-EAS-ic pathway compared to conventional hospitalization, in terms of all-cause death and unscheduled HF hospitalization at 6 months.

A randomized, prospective, (NCT04878263) was conducted from June 2021 to June 2023, involving two groups of patients in a 1:2 ratio: (A) a control group following the conventional hospitalization pathway, and (B) the experimental group following the FIL-EAS-ic pathway and including HaH when possible.

361 patients were included (454 planned) and intention-to-treat analysis was carried out on 349 patients. The population had the following well balanced characteristics: 78.9±11.7 years, female 43%, LVEF>0.40 48%, with main reason for AHF hospitalization: congestive heart failure 57%, pulmonary edema 38%, right heart failure 3%, cardiogenic shock 5%. Analysis of the primary objective showed statistical non-inferiority (A) 33% vs. 25% (B), P<0.001, without being able to demonstrate superiority (P Log-rank=0.151, HR 0.74 [0.49,1.12]) (Fig. 1). In group B, 67% were admitted to HaH, resulting in a lower in hospital length of stay of 8.9±5.5 days (A) vs 5.8±5.2 days (B), P<0.001. Moreover, access to HF education was higher (39% vs 7%, P<0.001), as was the rate of vaccination against pneumococcus (53% vs 20%, P<0.001) and COVID (91% vs 83%, P=0.033), and the prescription of sacubitril-valsartan in HFREF (55% vs 23%, P<0.001).

FIL-EAS-ic shows, in a very elderly population, that an HF team management of patients hospitalized for AHF, including early HaH hospitalization, is similar to conventional care, with a much shorter length of stay, and a higher quality in terms of access to education, vaccines and treatment.