Research ArticleResearchPatient Education

Weekly nurse-led phone follow-up cut 6-month heart failure rehospitalizations from 46% to 26%

Journal of the American Heart Association (PubMed)Mar 18, 2025

AI-summarized from the linked source. Educational brief, not medical advice.

Brief summary

In a randomized trial, weekly nurse-led telephone follow-up cut 6-month heart-failure rehospitalizations from 46% to 26%.

What NurseJet pulled from the source

This multicenter RCT across six public hospitals in Brazil randomized 127 heart failure patients to weekly nurse phone follow-up (tracking weight, blood pressure, heart rate, decompensation signs, and adherence, plus text-message education) or usual care. At 180 days, HF-related rehospitalization was 26% with the intervention versus 46% with usual care (RR 0.56, P<0.02), and the composite of death or rehospitalization was 30% versus 47% (RR 0.63, P=0.04). The benefit held even though the population was high-risk and underserved.

Why this matters for nurses

Telemetry and cardiac nurses spend a lot of energy on the discharge teaching that decides whether a heart failure patient bounces back. This trial suggests a simple structured weekly nurse phone check may matter because it catches early congestion before it becomes a readmission, and it worked even where you might expect technology-based follow-up to fail.

Bedside takeaway

Worth knowing that a simple weekly nurse-led phone check tracking weight, blood pressure, heart rate, decompensation signs, and adherence cut 6-month heart failure rehospitalizations from 46% to 26%.

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Key takeaways

Weekly nurse-led phone follow-up cut HF-related rehospitalizations at 180 days from 46% to 26% (RR 0.56, P<0.02).
Death or rehospitalization was also lower with the intervention (30% vs 47%; RR 0.63, P=0.04).
Calls tracked weight, blood pressure, heart rate, decompensation signs, and adherence, paired with text-message education.
The intervention worked in a high-risk, lower-literacy, lower-resource population (mean age 64; 65% NYHA class III/IV).

Practice implications

Before a heart failure patient leaves, reinforce daily morning weights and a clear 'call if you gain weight or get more short of breath' plan, and teach weight, blood pressure, heart rate, decompensation signs, and adherence as a bundle. Advocate for structured nurse-led phone follow-up, and don't assume low health literacy rules a patient out of it.

Limitations & cautions

This was a small single-country trial (127 patients across six Brazilian public hospitals), so absolute event rates may not transfer directly elsewhere. An open-label behavioral intervention cannot be blinded and was not powered for mortality, so the survival signal should be read cautiously.
AI-summarized from the linked source. Review the original article before applying to practice.

Citations

Exact source links

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Journal of the American Heart Association (PubMed)

Journal of the American Heart Association (PubMed). Effect of Telemedicine Interventions on Heart Failure Hospitalizations: A Randomized Trial.

Open original source

https://pubmed.ncbi.nlm.nih.gov/40055862/

Professional education only

This summary does not replace clinical judgment, facility policy, provider orders, or official guidelines. Verify practice changes against the original source and local protocol.

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Journal of Cardiovascular Nursing (PubMed)Jul 3, 2026Research Article

In a prospective study of 126 adults with heart failure, better symptom monitoring and management were associated with being physically frail, but physical frailty itself predicted worse 6-month clinical outcomes no matter how adequately patients monitored their symptoms.

Telemetry GeriatricsAI summaryReview source

Research ArticleResearchPatient EducationAI summary · original source linked below

This prospective observational study enrolled 126 adults with New York Heart Association (NYHA) functional class II to IV heart failure. Physical frailty was assessed with the Frailty Phenotype Criteria and symptom monitoring and management (SMM) behaviors with the Self-Care of Heart Failure Index (v7.2). The sample averaged 68.3 plus or minus 12.6 years, was 48% female, mostly NYHA Class III (54%), and largely nonischemic (73%); 43 participants (34%) were physically frail. After adjusting for a mortality risk score, better symptom monitoring (P = .037) and better symptom management (P = .023) were each associated with physical frailty. In Cox regression, physical frailty was associated with significantly worse 6-month clinical event risk irrespective of the adequacy of symptom monitoring, and the combination of frailty and symptom management did not predict 6-month events. The authors suggest frailty may drive patients to engage in better self-care while remaining an important predictor of risk.

Key takeaways

Among 126 adults with heart failure, 43 (34%) were physically frail.
Better symptom monitoring (P = .037) and better symptom management (P = .023) were each associated with being physically frail, after adjusting for mortality risk.
Physical frailty was associated with significantly worse 6-month clinical event risk regardless of how adequately patients monitored their symptoms.
The authors suggest physical frailty may drive better self-care yet remains an independent marker of clinical risk.

Why this matters on shift

Heart failure self-care, weighing daily, tracking symptoms, and adjusting fluids, is a large part of what cardiac nurses teach. This study may matter for nurses because it suggests that even patients who monitor and manage their symptoms well can still face higher 6-month risk if they are physically frail, pointing to frailty as a red flag that self-care education alone may not offset.

Bedside takeaway

Be aware that in this heart failure cohort, physical frailty predicted worse 6-month outcomes regardless of how well patients monitored their symptoms, so frailty may flag risk that self-care alone does not offset.

Nursing implications

For cardiology and telemetry nurses, the findings suggest that noticing physical frailty in heart failure patients, alongside teaching symptom monitoring, may help identify those at higher risk over the next six months. Because this was an observational study, frailty assessment should complement rather than replace existing risk tools and discharge teaching, and any change in care planning belongs with the heart failure team.

Limitations & cautions

This was a single prospective observational cohort of 126 adults, so it shows associations rather than cause and effect, and cannot establish that addressing frailty changes outcomes. Symptom behaviors were self-reported, the sample was mostly NYHA Class III with nonischemic heart failure, and follow-up was limited to six months, so results may not generalise to all heart failure populations.
AI-summarized from the linked source. Review the original article before applying to practice.

Citations · exact source links

Journal of Cardiovascular Nursing (PubMed). Physical Frailty, Self-Care Behaviors, and 6-Month Clinical Outcomes Among Adults With Heart Failure.

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Journal of Emergency Nursing (PubMed)Jun 30, 2026Research Article

In a retrospective cohort of 1076 adults aged 40 or older with acute myocardial infarction at a Taiwan teaching hospital, 19% presented without chest-related symptoms, and reduced level of consciousness and greater functional dependence were each independently linked to these atypical presentations.

Emergency TelemetryAI summaryReview source

Research ArticleResearchAI summary · original source linked below

This retrospective cohort study used electronic health record data from a regional teaching hospital in Taiwan, including 1076 adults aged 40 years or older diagnosed with acute myocardial infarction between 2016 and 2023. Presentations were classified as typical (chest pain or chest tightness) or atypical (absence of chest-related symptoms). Among the 1076 patients, 19.0% presented without any chest-related symptoms. Patients with atypical presentations were older, had lower body mass index, greater dependence in activities of daily living, and lower Glasgow Coma Scale scores. In multivariable logistic regression, reduced level of consciousness (odds ratio 4.93; 95% CI 2.41 to 10.05; P < .001) and greater functional dependence (odds ratio 1.10; 95% CI 1.06 to 1.15; P < .001) were each independently associated with atypical presentation.

Key takeaways

Among 1076 adults aged 40 or older with acute myocardial infarction, 19.0% presented without any chest-related symptoms.
Reduced level of consciousness was independently associated with atypical presentation (odds ratio 4.93; 95% CI 2.41 to 10.05; P < .001).
Greater functional dependence in activities of daily living was also independently associated (odds ratio 1.10; 95% CI 1.06 to 1.15; P < .001).
Patients with atypical presentations tended to be older with lower body mass index and lower Glasgow Coma Scale scores.

Why this matters on shift

Emergency nurses are often the first to size up a patient at triage, and chest pain is widely treated as the signature of a heart attack. This study may matter for nurses because nearly one in five confirmed myocardial infarctions arrived without chest symptoms, and the patients most likely to present atypically were those with cognitive or functional impairment who can least advocate for themselves.

Bedside takeaway

Be aware that in this cohort about 1 in 5 confirmed heart attacks came without chest symptoms, and atypical presentation was more likely in patients with reduced consciousness or greater functional dependence.

Nursing implications

For emergency nurses, the findings suggest a heart attack cannot be ruled out on the absence of chest pain alone, especially in older adults or those with reduced consciousness or high dependence in activities of daily living. Folding functional status and Glasgow Coma Scale into the triage picture, and keeping a lower threshold for cardiac workup in impaired patients, may help catch atypical presentations earlier.

Limitations & cautions

This was a single-center retrospective cohort at one regional teaching hospital in Taiwan, drawing on electronic health record data from 2016 to 2023, so practice and documentation patterns may not generalize elsewhere. The observational design shows association, not causation, and only patients already diagnosed with acute myocardial infarction were included, so the study cannot speak to how often atypical presentations are missed entirely.
AI-summarized from the linked source. Review the original article before applying to practice.

Citations · exact source links

Journal of Emergency Nursing (PubMed). Emergency Nursing Recognition of Atypical Acute Myocardial Infarction: Associations With Functional Status and Level of Consciousness-A Retrospective Cohort Study.

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Journal of Clinical Nursing (PubMed)Apr 1, 2024Systematic Review

A systematic review and meta-analysis found that nurse-led self-care interventions improved quality of life, anxiety, and symptom burden in people with heart failure.

TelemetryAI summaryReview source

Systematic ReviewResearchPatient EducationAI summary · original source linked below

Across 25 randomized controlled trials and 2,746 participants, nurse-led self-care interventions improved quality of life (SMD 0.83), anxiety (MD 1.39, high-certainty evidence), and symptom burden (SMD 0.81) versus usual care. No significant effect was seen on all-cause readmission or emergency department visits, and effects on mortality and sleep quality were unclear.

Key takeaways

Across 25 RCTs and 2,746 patients, nurse-led self-care improved quality of life, anxiety, and symptom burden.
The anxiety benefit was supported by high-certainty evidence.
No significant effect was seen on all-cause readmission or ED visits.
Effects on mortality and sleep quality were unclear.

Why this matters on shift

Heart failure self-care, including daily weights, sodium and fluid awareness, symptom recognition, and medication adherence, is taught and reinforced largely by nurses. This may matter for nurses because it gives meta-analytic support that structured nurse-led teaching improves how patients feel and cope, even where it did not change readmissions.

Bedside takeaway

Be aware that nurse-led heart failure self-care teaching improved quality of life, anxiety, and symptom burden, but did not significantly change readmissions or emergency department visits.

Nursing implications

Prioritize structured heart failure self-care teaching such as daily weights, symptom tracking, sodium and fluid guidance, and medication adherence, use teach-back to confirm understanding, and set realistic expectations that the strongest gains were in quality of life and symptoms rather than readmissions.

Limitations & cautions

Certainty varied by outcome, and effects on readmission and mortality were not demonstrated. Interventions differed across trials, so the exact dose of teaching that helps is unclear.
AI-summarized from the linked source. Review the original article before applying to practice.

Citations · exact source links

Journal of Clinical Nursing (PubMed). Effects of nurse-led self-care interventions on health outcomes among people with heart failure: A systematic review and meta-analysis.

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Open original sourceFull brief

AI-summarized from the linked source. Review the original article before applying to practice.

Key takeaways

Practice implications

Limitations & cautions

Exact source links

More updates for this clinical area

In heart failure, physical frailty predicted worse 6-month outcomes regardless of how well patients monitored their symptoms

Nearly 1 in 5 confirmed heart attacks arrived without chest symptoms, more often in patients with impaired function or consciousness

Nurse-led self-care programs improved quality of life and anxiety in heart failure patients