Multidisciplinary team approach to heart failure management

An Expert Opinion on the Management of Frailty in Heart Failure from the Australian Cardiovascular Alliance National Taskforce

Approximately 50% of all adults with heart failure (HF) are classified as frail. Frailty is a clinical state of 'accelerated ageing' that complicates management and results in adverse health outcomes. Despite recommendations for frailty assessment in HF guidelines, its implementation into routine clinical practice has been slow. Further, evidence to inform models of care and pharmacological treatment for individuals with HF who are classified as frail is lacking. The complexity of management underscores the importance of tailoring models of care that can improve the focus on frailty through multidisciplinary care teams. Frailty can be reduced in some cases through the comprehensive geriatric assessment model of care, integrating treatment pillars such as exercise, nutrition, social engagement and support networks, and optimised medication use. A national agenda for action on frailty in the context of HF is needed to advance policy, practice, education, and research improve health outcomes for individuals affected. In November 2023 the Australian Cardiovascular Alliance (ACvA) facilitated a national workshop on frailty and HF with key experts. This has led to the development of a frailty and HF national taskforce with the aim to address major priorities and unmet needs. This statement is first step for the taskforce in implementing a national agenda for the management of frailty in HF. Here we outline key considerations for policy, practice, education, and research in Australia.

Association between visit frequency, continuity of care, and pharmacy fill adherence in heart failure patients

BACKGROUND

Despite advances in medical therapy for heart failure with reduced ejection fraction (HFrEF), major gaps in medication adherence to guideline-directed medical therapies (GDMT) remain. Greater continuity of care may impact medication adherence and reduced hospitalizations.

METHODS

We conducted a cross-sectional study of adults with a diagnosis of HF and EF ≤40% with ≥2 outpatient encounters between January 1, 2017 and January 10, 2021, prescribed ≥1 of the following GDMT: 1) Beta Blocker, 2) Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker/Angiotensin Receptor Neprilysin Inhibitor, 3) Mineralocorticoid Receptor Antagonist, 4) Sodium Glucose Cotransporter-2 Inhibitor. Continuity of care was calculated using the Bice-Boxerman Continuity of Care Index (COC) and the Usual Provider of Care (UPC) index, categorized by quantile. The primary outcome was adherence to GDMT, defined as average proportion of days covered ≥80% over 1 year. Secondary outcomes included all-cause and HF hospitalization at 1-year. We performed multivariable logistic regression analyses adjusted for demographics, insurance status, comorbidity index, number of visits and neighborhood SES index.

RESULTS

Overall, 3,971 individuals were included (mean age 72 years (SD 14), 71% male, 66% White race). In adjusted analyses, compared to individuals in the highest COC quartile, individuals in the third COC quartile had higher odds of GDMT adherence (OR 1.26, 95% CI 1.03-1.53, P = .024). UPC tertile was not associated with adherence (all P > .05). Compared to the highest quantiles, the lowest UPC and COC quantiles had higher odds of all-cause (UPC: OR 1.53, 95%CI 1.23-1.91; COC: OR 2.54, 95%CI 1.94-3.34) and HF (UPC: OR 1.81, 95%CI 1.23-2.67; COC: OR 1.77, 95%CI 1.09-2.95) hospitalizations.

CONCLUSIONS

Continuity of care was not associated with GDMT adherence among patients with HFrEF but lower continuity of care was associated with increased all-cause and HF-hospitalizations.

Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note

PURPOSE

The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD).

TECHNIQUE

We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks.

CONCLUSIONS

Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable.

CLINICAL IMPACT

The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.

conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT)

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future.

METHODS

A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses.

RESULTS

Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses.

CONCLUSION

This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.

Assessing and Improving the Care of Patients With Heart Failure in Ghana: Protocol for a Prospective Observational Study and the Ghana Heart Initiative-Heart Failure Registry

BACKGROUND

Heart failure (HF) is a leading cause of morbidity and mortality globally, with a high disease burden. The prevalence of HF in Ghana is increasing rapidly, but epidemiological profiles, treatment patterns, and survival data are scarce. The national capacity to diagnose and manage HF appropriately is also limited. To address the growing epidemic of HF, it is crucial to recognize the epidemiological characteristics and medium-term outcomes of HF in Ghana and improve the capability to identify and manage HF promptly and effectively at all levels of care.

OBJECTIVE

This study aims to determine the epidemiological characteristics and medium-term HF outcomes in Ghana.

METHODS

We conducted a prospective, multicenter, multilevel cross-sectional observational study of patients with HF from January to December 2023. Approximately 5000 patients presenting with HF to 9 hospitals, including teaching, regional, and municipal hospitals, will be recruited and evaluated according to a standardized protocol, including the use of an echocardiogram and an N-terminal pro-brain natriuretic peptide (NT-proBNP) test. Guideline-directed medical treatment of HF will be initiated for 6 months, and the medium-term outcomes of interventions, including rehospitalization and mortality, will be assessed. Patient data will be collated into a HF registry for continuous assessment and monitoring.

RESULTS

This intervention will generate the necessary information on the etiology of HF, clinical presentations, the diagnostic yield of various tools, and management outcomes. In addition, it will build the necessary capacity and support for HF management in Ghana. As of July 30, 2023, the training and onboarding of all 9 centers had been completed. Preliminary analyses will be conducted by the end of the second quarter of 2024, and results are expected to be publicly available by the middle of 2024.

CONCLUSIONS

This study will provide the necessary data on HF, which will inform decisions on the prevention and management of HF and form the basis for future research.

TRIAL REGISTRATION

ISRCTN Registry (United Kingdom) ISRCTN18216214; https:www.isrctn.com/ISRCTN18216214.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52616.

Optimizing Heart Failure Management: A Review of the Clinical Pharmacist Integration to the Multidisciplinary Health Care Team

Heart failure (HF) stands as a prevalent chronic ailment, imposing a substantial burden on global healthcare systems due to recurrent hospitalizations, intricate management, persistent symptoms, and polypharmacy challenges. The augmentation of patient safety and treatment efficacy across various care stages, facilitated by a multidisciplinary HF team inclusive of a clinical pharmacist, emerges as paramount. Evidence underscores that the collaborative engagement of a physician and a clinical pharmacist engenders proficient and secure management, forestalling avoidable adversities stemming from drug reactions and prescription inaccuracies. This synergistic approach tailors treatments optimally to individual patients. Post-discharge, the vulnerability of HF patients to re-hospitalization looms large, historically holding sway as the foremost cause of 30-day readmissions. Diverse strategies have been instituted to fortify patient well-being, leading to the formulation of specialized transitional care programs that shepherd patients effectively from hospital to outpatient settings. These initiatives have demonstrably curtailed readmission rates. This review outlines a spectrum of roles assumed by clinical pharmacists within the healthcare cohort, spanning inpatient care, transitional phases, and outpatient services. Moreover, it traverses a compendium of studies spotlighting the affirmative impact instigated by integrating clinical pharmacists into these fields.

Cardiogenic Shock in Non-Ischemic Cardiomyopathy: Dynamic Mechanical Circulatory Support and Pathophysiology Illustration

Nonischemic cardiomyopathy (NICM) is a significant cause of cardiogenic shock (CS). We present a case of a 56-year-old previously healthy man who arrived with vague abdominal symptoms, over 2 weeks. Subsequently, the patient's condition rapidly deteriorated over 12 hours, leading to cardiogenic shock categorized as Society for Cardiovascular Angiography and Interventions (SCAI) stage D. Echocardiography and right heart catheterization confirmed multiorgan failure secondary to severe cardiac dysfunction. Mechanical circulatory support was initiated using an Impella CP device 20 hours after admission due to ongoing deterioration. Considering refractory cardiogenic shock and within 24 hours, the patient received combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella CP support (ECPElla). With gradual improvement in the patient's clinical status and organ function, successful weaning from VA ECMO to Impella 5.5 was achieved. Ultimately, the patient underwent a successful orthotopic heart and kidney transplantation, marking a significant milestone in his recovery. The case underscores the importance of promptly identifying and responding to cardiogenic shock through invasive hemodynamic assessment. Collaborative decision-making involving a multidisciplinary team played a crucial role in the initiation, escalation, and eventual weaning of mechanical circulatory support, culminating in the successful bridging to a dual organ transplantation for this patient with CS secondary to NICM.

Current status of outpatient heart failure management in Egypt and recommendations for the future

Heart failure (HF) represents one of the greatest healthcare burdens worldwide, and Egypt is no exception. HF healthcare programmes in Egypt still require further optimization to enhance diagnosis and management of the disease. Development of specialized HF clinics (HFCs) and their incorporation in the healthcare system is expected to reduce HF hospitalization and mortality rates and improve quality of care in Egypt. We conducted a literature search on PubMed on the requirements and essential infrastructure of HFCs. Retrieved articles deemed relevant were discussed by a panel of 10 expert cardiologists from Egypt and a basic HFC model for the Egyptian settings was proposed. A multidisciplinary team managing the HFC should essentially be composed of specialized HF cardiologists and nurses, clinical pharmacists, registered nutritionists, physiotherapists, and psychologists. Other clinical specialists should be included according to patients' needs and size and structure of individual clinics. HFCs should receive patients referred from primary care settings, emergency care units, and physicians from different specialties. A basic HFC should have the following fundamental investigations available: resting electrocardiogram, basic transthoracic echocardiogram, and testing for N-terminal pro-B-type natriuretic peptide. Fundamental patients' functional assessments are assessing the New York Heart Association functional classification and quality of life and conducting the 6 min walking test. guideline-directed medical therapy should be implemented, and device therapy should be utilized when available. In the first visit, once HF is diagnosed and co-morbidities assessed, guideline-directed medical therapy should be started immediately. Comprehensive patient education sessions should be delivered by HF nurses or clinical pharmacists. The follow-up visit should be scheduled during the initial visit rather than over the phone, and time from the initial visit to the first follow-up visit should be determined based on the patient's health status and needs. Home and virtual visits are only recommended in limited and emergency situations. In this paper, we provide a practical and detailed review on the essential components of HFCs and propose a preliminary model of HFCs as part of a comprehensive HF programme model in Egypt. We believe that other low-to-middle income countries could also benefit from our proposed model.

An overview of chronic heart failure

Heart failure (HF) is associated with high morbidity and mortality and is a significant public health concern. Globally, the prevalence of HF is increasing and prognosis remains suboptimal for people with the condition. HF has significant effects on patients, their families and healthcare services. People with HF can present with acute or chronic signs and symptoms. This article provides an overview of HF including its prevalence, pathophysiology, causes, diagnosis and management. It details the pharmacological treatments that may be used and the nurse's role in caring for patients with the condition.

Broadening Heart Failure Care Beyond Cardiology: Challenges and Successes Within the Landscape of Multidisciplinary Heart Failure Care

PURPOSE OF REVIEW

Heart failure (HF) is a growing public health concern that impairs the quality of life and is associated with significant mortality. As the prevalence of heart failure increases, multidisciplinary care is essential to provide comprehensive care to individuals.

RECENT FINDINGS

The challenges of implementing an effective multidisciplinary care team can be daunting. Effective multidisciplinary care begins at the initial diagnosis of heart failure. The transition of care from the inpatient to the outpatient setting is critically important. The use of home visits, case management, and multidisciplinary clinics has been shown to decrease mortality and heart failure hospitalizations, and major society guidelines endorse multidisciplinary care for heart failure patients. Expanding heart failure care beyond cardiology entails incorporating primary care, advanced practice providers, and other disciplines. Patient education and self-management are fundamental to multidisciplinary care, as is a holistic approach to effectively address comorbid conditions. Ongoing challenges include navigating social disparities within heart failure care and limiting the economic burden of the disease.

Community pharmacists' perceptions on multidisciplinary heart failure care: an exploratory qualitative study

BACKGROUND

Heart failure (HF) is an important health problem and guidelines recommend multidisciplinary management. The pharmacist is an important member of the multidisciplinary heart failure team, both in the hospital and community setting. This study aims to explore the perceptions of community pharmacists on their role in HF care.

METHODS

We conducted a qualitative study based on face-to-face semi-structured interviews with 13 Belgian community pharmacists between September 2020 and December 2020. We used the Qualitative Analysis Guide of Leuven (QUAGOL) method as guidance for data analysis until data saturation was reached. We structured interview content into a thematic matrix.

RESULTS

We identified two major themes: heart failure management and multidisciplinary management. Pharmacists feel responsible for the pharmacological and non-pharmacological management of heart failure, citing easy access and pharmacological expertise as important assets. Diagnostic uncertainty, lack of knowledge and time, disease complexity and difficulties in communication with patients and informal care providers are barriers to optimal management. General practitioners are the most important partners in multidisciplinary community heart failure management, although pharmacists perceive a lack of appreciation and cooperation and deplore communication difficulties. They feel intrinsically motivated to provide extended pharmaceutical care in HF but cite the lack of financial viability and information sharing structures as important barriers.

CONCLUSION

The importance of pharmacist involvement in multidisciplinary heart failure teams is undisputed by Belgian pharmacists, who cite easy access and pharmacological expertise as important assets. They point out several barriers impeding evidence-based pharmacist care for outpatients with heart failure: diagnostic uncertainty and disease complexity, lack of multidisciplinary information technology and insufficient resources. We recommend that future policy should focus on improved medical data exchanges between primary and secondary care electronic health records as well as the reinforcement of interprofessional relationships between locally affiliated pharmacists and general practitioners.

Multidisciplinary Care in Heart Failure Services

The American College of Cardiology/American Heart Association/Heart Failure Society of American 2022 guidelines for heart failure (HF) recommend a multidisciplinary team approach for patients with HF. The multidisciplinary HF team-based approach decreases the hospitalization rate for HF and health care costs and improves adherence to self-care and the use of guideline-directed medical therapy. This article proposes the optimal multidisciplinary team structure and each team member's delineated role to achieve institutional goals and metrics for HF care. The proposed HF-specific multidisciplinary team comprises cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians. A standardized multidisciplinary HF team-based approach should be incorporated to optimize the structure, minimize the redundancy of clinical responsibilities among team members, and improve clinical outcomes and patient satisfaction in their HF care.

Treatment Strategies of Improving Quality of Care in Patients With Heart Failure

Heart failure (HF) is a global health problem closely related to morbidity and mortality. As the burden of HF increases, it is necessary to manage and treat this condition well. However, there are differences between real-world practice and guidelines for the optimal treatment for HF. Patient-related, healthcare provider-related, and health system-related factors contribute to poor adherence to optimal care. This review article aims to examine HF treatment patterns and treatment adherence in real-world practice, identify clinical gaps to suggest ways to improve the quality of care for HF and clinical outcomes for patients with HF. Although it is important to optimize treatment based on evidence-based guidelines to the greatest extent, it is known that there is still poor treatment adherence, and many patients do not receive guideline-directed medical therapy, especially at the early stages. To improve medication adherence, qualitative evaluation through performance measurement, as well as education of patients, caregivers and medical staff through a multidisciplinary approach are important.

Endovascular Baroreflex Amplification With the MobiusHD Device in Patients With Heart Failure and Reduced Ejection Fraction: Interim Analysis of the First-in-Human Results

Background

Endovascular baroreflex amplification with the MobiusHD, a self-expanding stent-like device that is implanted in the internal carotid artery, was designed to reduce the sympathetic overactivity that contributes to progressive heart failure with reduced ejection fraction.

Methods

Symptomatic patients (New York Heart Association class III) with heart failure with reduced ejection fraction (left ventricular ejection fraction [LVEF] ≤40%) despite guideline directed medical therapy and n-terminal pro-B type natriuretic peptide (NT-proBNP) levels ≥400 pg/mL in whom carotid ultrasound and computed tomographic angiography demonstrated absence of carotid plaque were enrolled. Baseline and follow-up measures included 6-minute walk distance (6MWD), Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ OSS), and repeat biomarkers and transthoracic echocardiography.

Results

Twenty-nine patients underwent device implantation. The mean age was 60.6 ± 11.4 years, and all had New York Heart Association class III symptoms. Mean KCCQ OSS was 41.4 ± 12.7, mean 6MWD was 216.0 ± 43.7 m, median NT-proBNP was 1005.9 pg/mL (894, 1294), and mean LVEF was 34.7 ± 2.9%. All device implantations were successful. Two patients died (161 days and 195 days) and one stroke occurred (170 days) during follow-up. For the 17 patients with 12-month follow-up, mean KCCQ OSS improved by 17.4 ± 9.1 points, mean 6MWD increased by 97.6 ± 51.1 meters, a mean 28.4% reduction from the baseline NT-proBNP concentration was found, and mean LVEF improved by 5.6% ± 2.9 (paired data).

Conclusion

Endovascular baroreflex amplification with the MobiusHD device was safe and effected positive changes in quality of life, exercise capacity, and LVEF, consistent with observed reductions in NT-proBNP levels.

Device-based therapy for decompensated heart failure: An updated review of devices in development based on the DRI2P2S classification

Congestive heart failure (HF) is a devastating disease leading to prolonged hospitalization, high morbidity and mortality rates, and increased costs. Well-established treatments for decompensated or unstable patients include medications and mechanical cardiac support devices. For acute HF decompensation, new devices are being developed to help relieve symptoms and recover heart and renal function in these patients. A recent device-based classification scheme, collectively classified as DRI2P2S, has been proposed to better describe these new device-based therapies based on their mechanism: dilators (increase venous capacitance), removers (direct removal of sodium and water), inotropes (increase left ventricular contractility), interstitials (accelerate removal of lymph), pushers (increase renal arterial pressure), pullers (decrease renal venous pressure), and selective (selective intrarenal drug infusion). In this review, we describe the new class of medical devices with the most current results reported in preclinical models and clinical trials.

Multispecialty multidisciplinary input into comorbidities along with treatment optimisation in heart failure reduces hospitalisation and clinic attendance

Aims

Heart failure (HF) is associated with comorbidities which independently influence treatment response and outcomes. This retrospective observational study (January 2020–June 2021) analysed the impact of monthly HF multispecialty multidisciplinary team (MDT) meetings to address management of HF comorbidities and thereby on provision, cost of care and HF outcomes.

Methods

Patients acted as their own controls, with outcomes compared for equal periods (for each patient) pre (HF MDT) versus post-MDT (multispecialty) meeting. The multispecialty MDT comprised HF cardiologists (primary, secondary, tertiary care), HF nurses, nephrologist, endocrinologist, palliative care, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were (1) all-cause hospitalisations, (2) outpatient clinic attendances and (3) cost.

Results

334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9±4 months. Mean age-adjusted Charlson Comorbidity Index was 7.6±2.1 and Rockwood Frailty Score 5.5±1.6. Multispecialty interventions included optimising diabetes therapy (haemoglobin A1c-HbA1c pre-MDT 68±11 mmol/mol vs post-MDT 61±9 mmol/mol; p<0.001), deprescribing to reduce anticholinergic burden (pre-MDT 1.85±0.4 vs 1.5±0.3 post-MDT; p<0.001), initiation of renin–angiotensin aldosterone system inhibitors in HF with reduced ejection fraction (HFrEF) with advanced chronic kidney disease (9% pre vs 71% post-MDT; p<0.001). Other interventions included potassium binders, treatment of anaemia, falls assessment, management of chest conditions, day-case ascitic, pleural drains and palliative support. Total cost of funding monthly multispecialty meetings was £32 400 and resultant 64 clinic appointments cost £9600. The post-MDT study period was associated with reduction in 481 clinic appointments (cost saving £72150) and reduced all-cause hospitalisations (pre-MDT 1.1±0.4 vs 0.6±0.1 post-MDT; p<0.001), reduction of 1586 hospital bed-days and cost savings of £634 400. Total cost saving to the healthcare system was £664 550.

Conclusion

HF multispecialty virtual MDT model provides integrated, holistic care across all healthcare tiers for management of HF and associated comorbidities. This approach is associated with reduced clinic attendances and all-cause hospitalisations, leading to significant cost savings.

Favorable Impact of a Multidisciplinary Team Approach on Heart Transplantation Outcomes in a Mid-Volume Center

Although a multidisciplinary team (MDT) approach is recommended for advanced heart failure and heart transplantation (HTx), no studies have investigated the impact of the team approach on post-HTx survival. Thus, we implemented an MDT approach in our HTx program in 2014, with the active involvement of critical care and extracorporeal life support (ECLS) teams and the use of a real-time online information sharing system. We hypothesized that this MDT approach would result in improved survival of patients who had undergone HTx. We enrolled 250 adult patients who underwent HTx between December 2003 and June 2018. They were divided into non-MDT (n = 120; before 2014) and MDT (n = 130; since 2014) groups. The primary outcome was overall mortality. In terms of donor age, diabetes, dialysis, ECLS, and waiting time, the MDT group had more high-risk patients. The MDT approach was found to be an independent predictor of overall survival using a variety of multivariable analytic methods, including inverse probability of treatment weighting analysis. An HF team, a critical care team, and an ECLS team collaboration may improve survival following HTx. To improve the efficiency of the MDT approach, we recommend using a real-time online information sharing system.

SGLT-2 inhibitors for treatment of heart failure in patients with and without type 2 diabetes: A practical approach for routine clinical practice

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i), initially studied and approved for the treatment of diabetes, are now becoming a promising class of agents to treat heart failure (HF) and chronic kidney disease (CKD), even in patients without diabetes. While the potential benefits in several diseases (usually treated by different medical specialties) is amplifying the interest in these drugs, their use in frail patients with multiple pathologies and on polypharmacy can be complex, requiring a composite multidisciplinary approach. Following a brief overview of the evidence supporting the benefits of SGLT-2i in patients with HF or CKD, we herein provide guidance for prescribing SGLT-2i in daily practice using a multidisciplinary approach. A shared treatment algorithm is presented for initiating an SGLT-2i in patients already being treated for diabetes and HF. Tools to prevent hypoglycemia, blood pressure drop, genital infections, euglycemic diabetic ketoacidosis and eGFR dip are also provided. It is hoped that this practical, multidisciplinary guidance for initiating SGLT-2i in patients with HF and/or CKD, whatever therapy they are currently on, can help to offer SGLT-2i to the largest population of patients possible to provide the most therapeutic benefit.

Prevalence and characteristics of patients with heart failure needing palliative care

Background

Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems.

Methods

This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (–NECPAL).

Results

Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to –NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems.

Conclusion

The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00850-y.

Egyptian Atherosclerosis and Vascular Biology Association Consensus on the Use of Sodium Glucose Cotransporter-2 Inhibitors in Heart Failure with Reduced Ejection Fraction

Heart failure (HF) is a common cause of cardiovascular mortality and morbidity. Despite advances in treatment, the prognosis remains poor. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors decrease HF events by 27-39% in high-risk patients with type 2 diabetes mellitus (T2DM). Moreover, the DAPA-HF and EMPEROR-Reduced studies randomized patients with HF with reduced ejection fraction (HFrEF) with or without diabetes mellitus to receive guideline-directed medical therapy versus guideline-directed medical therapy plus an SGLT-2 inhibitor. Both studies showed the benefits of SGLT-2 inhibitors. In addition, SGLT-2 inhibitors have shown improvement according to the EMPEROR-Preserved study of HF with preserved ejection fraction (HFpEF). Therefore, a panel of cardiology experts from the Egyptian Atherosclerosis and Vascular Biology Association (EAVA) revised the literature for SGLT-2 inhibitors in HF, along with the recommended indications and contraindications, and this article presents their consensus on the topic. The panel concluded that SGLT-2 inhibitors have significantly benefited patients with chronic HFrEF, as indicated through the DAPA-HF and EMPEROR-Reduced trials. The panel recommended early use of dapagliflozin 10 mg or empagliflozin 10 mg in patients with symptomatic chronic HFrEF, whether diabetic or non-diabetic, to ameliorate HF hospitalization rate, mortality, symptoms, and decline in renal function.

The impact of a community-based heart failure multidisciplinary team clinic on healthcare utilization and costs

Aims

Multidisciplinary team (MDT) management in heart failure (HF) is recommended to reduce mortality and HF hospitalization. We investigated whether an MDT in a community‐based HF unit (HFU) impacted patients' healthcare utilization (HCU) and costs.

Methods and results

A retrospective cohort study was conducted among HF patients who visited at least once in a regional community‐based HFU, established for ambulatory specialist care for New York Heart Association Functional Classes III and IV, between January 2012 and August 2019. HCU data were obtained from the health maintenance organization's claims data for 12 months before and after first HFU visit. Multivariable generalized estimating equation models were specified for the annual average change in total healthcare utilization and hospitalization costs. Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow‐up (Group A) and 119 (12.4%) died within 12 months following their first visit (Group B). Both groups were comparable regarding sex, socio‐economic status, Charlson Comorbidity Index, ischaemic heart disease, and/or carotid artery disease. Those who died within 12 months were older and had more hypertension, diabetes, chronic renal disease, and malignancy. There was a significant reduction in the total average annual HCU costs of the entire study population 12 months after the first HFU visit [$12 675 (±17 210) after vs. $13 188 (±15 011) before, P = 0.014]. This was driven by a reduction in costs among patients who completed 12 months of follow‐up [$11 955 (±17 352) after vs. $13 112 (±15 268) before, P < 0.001], whereas an increase in these costs was observed among patients who died during follow‐up [$17 774 (±15 292) after vs. $13 728 (±13 093) before, P = 0.015]. These opposite trends stem mainly from a decrease [$3540 (±8991) after vs. $4941 (±6806) before, P < 0.001] vs. increase [$10 932 (±11 660) after vs. $6733 (±7215) before, P = 0.002] in hospitalization costs of these groups, respectively. The multivariable models revealed that patients who died within 12 months following the first visit to the HFU demonstrated a significant increase of 57% in hospitalization costs following their first visit [relative risk (RR) = 1.57, 95% confidence interval (CI): 1.20–2.05, P = 0.001], whereas there was a decrease of 34% in the hospitalization costs of patients who completed 12 months of follow‐up after their first visit (RR = 0.66, 95% CI: 0.54–0.81, P < 0.001). The entire cohort demonstrated 27% decrease in hospitalization costs following their first HFU visit (RR = 0.73, 95% CI: 0.62–0.87, P < 0.001).

Conclusions

Intensification of therapy by a dedicated MDT significantly reduced healthcare utilization and costs, predominantly due to a decrease in hospitalizations.

Pathophysiology and Therapeutic Approaches to Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.

Cardiologists' perceptions on multidisciplinary collaboration in heart failure care - a qualitative study

BACKGROUND

Cardiologists play a key role in multidisciplinary care by guiding heart failure (HF) management in the hospital and in the community. Regional implementation of multidisciplinary health care interventions depends on how they perceive collaboration with other health care disciplines, yet research on this topic is limited. This study aimed to explore the views and opinions of cardiologists on multidisciplinary collaboration in HF care.

METHODS

We conducted a qualitative study based on face-to-face semi-structured interviews with 11 Belgian cardiologists between September 2019 and February 2020. We used the Qualitative Analysis Guide of Leuven (QUAGOL) method as guidance for data analysis until data saturation was reached.

RESULTS

Cardiologists consider the general practitioner (GP) and HF nurse as the most important partners in HF management. Cardiologists identified four problems in current multidisciplinary collaboration: the communication of a HF diagnosis to the patient, advanced care planning, titration of HF medication by the GP and electronic data exchange and communication. Three themes emerged as ideas for improvement of HF care: 1) expansion of the role of the HF nurse, 2) implementation of a structured, patient-centered, and flexible model of disease management program and 3) integrated data approaches.

CONCLUSION

Cardiologists value close cooperation with GPs in HF management. They advocate an expanded future role for the HF nurse, increased eHealth, and structured disease management to optimize current HF care.

Characteristics and outcomes of patients with suspected heart failure referred in line with National Institute for Health and Care Excellence guidance

OBJECTIVE

To describe the population, heart failure (HF) diagnosis rate, and 1-year hospitalisation and mortality of patients with suspected HF and elevated N-terminal pro B-type natriuretic peptide (NTproBNP) investigated according to UK National Institute for Health and Care Excellence (NICE) guidelines.

METHODS

NICE recommends patients with suspected HF, based on clinical presentation and elevated NTproBNP, are referred for specialist assessment and echocardiography. Patients should be seen within 2 weeks when NTproBNP is >2000 pg/mL (2-week pathway: 2WP) or within 6 weeks when NTproBNP is 400-2000 pg/mL (6-week pathway: 6WP). This is a retrospective, multicentre, observational study of consecutive patients with suspected HF referred from primary care between 2014 and 2016 to dedicated secondary care HF clinics based on the NICE 2WP and 6WP. Data were obtained from hospital records and episode statistics. Mortality and hospitalisation rates were calculated 1 year from NTproBNP measurement.

RESULTS

1271 patients (median age 80; IQR 73-85) were assessed, 680 (53%) of whom were female. 667 (53%) were referred on the 2WP and 604 (47%) on the 6WP. 698 (55%) were diagnosed with HF (369 HF with reduced ejection fraction) and 566 (45%) as not HF (NHF). 1-year mortality was 10% (n=129) and hospitalisation was 33% (n=413). Patients on the 2WP had higher mortality and hospitalisation rates than those on the 6WP, 14% vs 6% (p<0.001) and 38% vs 27% (p<0.001), respectively. All-cause mortality (11% vs 9%; p=0.306) and hospitalisation rates (35% vs 29%; p=0.128) did not differ between HF and NHF patients, respectively.

CONCLUSIONS

Outcomes using the NICE approach of short waiting time targets for specialist assessment of patients with suspected HF and raised NTproBNP are not known. The model identifies an elderly population a high proportion of whom have HF. Irrespective of diagnosis, patients have high rates of adverse outcomes. These contemporary real-world data provide a platform for discussions with patients and shaping HF services.

A nurse practitioner-led effort to reduce 30-day heart failure readmissions

BACKGROUND

Heart failure (HF) affects over 6.5 million Americans and is the leading reason for hospital admissions in patients over the age of 65. Readmission rates within 30 days are 21.4% nationally, and 12% of those are likely preventable. Veterans are especially vulnerable to developing cardiac diseases requiring hospitalization and subsequent readmission.

LOCAL PROBLEM

The Southern Arizona Veterans Administration Health Care System has over 5,600 patients diagnosed with HF and a 30-day readmission rate of 21.65%. The aim of this quality improvement project was to reduce 30-day all-cause readmissions by 1% over 8 weeks.

METHODS

To reduce HF readmissions, the plan-do-study-act rapid-cycle method of quality improvement was used.

INTERVENTIONS

A dedicated multidisciplinary HF clinic was formed with a cardiology nurse practitioner, clinical pharmacists, and a dietician. A veteran-centered shared decision-making tool for setting self-care goals was implemented.

RESULTS

The readmission rate of patients seen in the multidisciplinary clinic (n = 33) was reduced by 0.2%. The percentage of veterans seen within 14 days increased from 30% to 54.5%. The average number of days between discharge and cardiology follow-up improved from 45 to 19 days. Veterans were able to set at least one self-care goal 87% of the time. Patient satisfaction with the multidisciplinary clinic was high at 93%.

CONCLUSIONS

Implementing a dedicated, multidisciplinary HF clinic reduced readmissions, improved timeliness of visits, and was well received. Use of a veteran-centered patient engagement tool resulted in more veterans setting self-care goals.

Nurses' perceptions of medical procedures and nursing practices for older patients with non-cancer long-term illness and do-not-attempt-resuscitation orders: A vignette study

Aim

To elucidate influence of a do-not-attempt-resuscitation (DNAR) order on nurses' perceptions of the medical procedures and nursing practices for non-cancer older patients.

Design

A vignette-based questionnaire study.

Methods

A questionnaire survey asking nurses their perceptions of clinical practices for the following three vignettes was performed in a community hospital in Japan (N = 120): the control vignettes with an older patient with repeated heart failure who was living alone and the other two with either an absence of relatives or a diagnosis of dementia. We also prepared additions to each vignette describing a DNAR order.

Results

Nurses' perception on cardiopulmonary resuscitation, defibrillation, blood tests and intravenous nutrition showed statistically significant and minimally important declines after the DNAR order compared with before for all three vignettes (p < .001). DNAR orders can influence nurses' perceptions of clinical practices for non-cancer older patients with chronic heart failure.

Health service use by patients with heart failure living in a community setting: a cross-sectional analysis in North West London

BACKGROUND

The complex nature of heart failure (HF) management, often involving multidimensional care, is widely recognised, but overall health service utilisation by patients with HF has not previously been described.

AIM

To describe overall health service use by adults with HF living in a community setting.

DESIGN AND SETTING

Cross-sectional analysis of prevalent HF cases from January 2015 to December 2018 using an administrative dataset covering primary and secondary care, and 'other' (community, mental health, social care) services in North West London.

METHOD

Healthcare use of each service was described overall and by individual components of secondary care (such as, outpatient appointments), and 'other' services (such as, nursing contacts). Usage patterns were identified using k-means cluster analysis, using all distinct contacts for the whole study period, and visualised with a heatmap.

RESULTS

A total of 39 301 patients with a prevalent diagnosis of HF between 1 January 2015 and 31 December 2018 were found. Of those, approximately 90% used health services during the study period, most commonly outpatient services, GP consultations, unplanned accident and emergency visits, and community services. Use of cardiology-specific services ranged from around 3% (cardiology-related community care) to around 20% (outpatient cardiology visits). GP consultations decreased by 11% over the study period. Five clusters of patients were identified, each with statistically significantly different care usage patterns and patient characteristics.

CONCLUSION

Patients with HF make heavy but heterogeneous use of services. Relatively low and falling use of GP consultations, and the apparently low uptake of community rehabilitation services by patients with HF, is concerning and suggests challenges in primary care access and integration of care.

Utilization of guideline-directed medical therapy in patients with de novo heart failure with reduced ejection fraction: A Veterans Affairs study

BACKGROUND

The utilization of guideline-directed medical therapy (GDMT) significantly reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Previous studies have documented the underutilization of GDMT in HFrEF. The present study aimed to determine reasons for underutilization and achievement of target doses of GDMT in patients with de novo diagnosis of HFrEF.

METHODS

Patients presenting with de novo HFrEF at the Veterans Affairs Medical Center were included. Baseline demographic, clinical, and echocardiographic data were collected. The utilization of target doses of GDMT was assessed at the time of discharge and 1-, 3-, 6-, and 12-month follow-up.

RESULTS

Of the 95 patients who met the criteria for de novo HFrEF, 48 were included in the final analysis. Dose titration of either beta-blocker or angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) was attempted in 20 patients (42%) at 1 month, 21 patients (44%) at 3 months, 13 patients (27%) at 6 months, and 14 patients (29%) at 12 months. Nine (19%) patients were on a target dose of beta-blockers and three (6%) patients were on a target dose of an ACEi/ARB at 12 months. The most common reasons for underutilization were patient-level factors, such as hypotension, acute kidney injury/hyperkalemia, and patient noncompliance.

CONCLUSIONS

Utilization and achievement of target doses of GDMT were suboptimal among patients discharged with de novo HFrEF during a 1-year follow-up. Although patient factors may limit the up-titration of therapies, concerted efforts are needed to support primary care physicians in improving adherence to target doses of GDMT in patients with HFrEF.

Barriers to Early Utilization of Palliative Care in Heart Failure: A Narrative Review

Palliative care is indicated in patients with heart failure since the early phases of the disease, as suggested by international guidelines. However, patients are referred to palliative care very late. Many barriers could explain the gap between the guidelines’ indications and clinical practice. The term palliative is perceived as a stigma by doctors, patients, and family members because it is charged with negative meanings, a poor prognosis, and no hope for improvement. Many authors prefer the term supportive care, which could facilitate a discussion between doctors, patients, and caregivers. There is substantial variation and overlap in the meanings assigned to these two terms in the literature. Prognosis, as the main indication to palliative care, delays its implementation. It is necessary to modify this paradigm, moving from prognosis to patients’ needs. The lack of access to palliative care programs is often due to a lack of palliative care specialists and this shortage will be greater in the near future. In this study, a new model is proposed to integrate early over the course of the disease the palliative care (PC) specialist in the heart failure team, allowing to overcome the barriers and to achieve truly simultaneous care in the treatment of heart failure (HF) patients.

Does specialist review for patients with suspected heart failure predict better outcomes? An observational study on the utility of compliance with NICE guidelines

OBJECTIVES

Compare outcomes in patients with suspected heart failure (HF) and raised natriuretic peptides who are reviewed in a specialist HF clinic in line with National Institute for Health and Care Excellence (NICE) guidelines (compliant group) versus patients who are not reviewed in the clinic (non-compliant group).

DESIGN

Retrospective observational study.

SETTING

Single large UK district general hospital.

PARTICIPANTS

567 consecutive patients in primary care with raised N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels (>400 pg/mL) from February to September 2014.

INTERVENTIONS

161 (28%) patients were referred to the specialist HF clinic and 406 (72%) were not. Outcomes were compared between the two groups.

OUTCOME MEASURES

All-cause and cardiovascular (CV) hospitalisations and all-cause mortality.

RESULTS

The compliant group were slightly younger than the non-compliant group (78±9 vs 80±9; p=0.019) but had much higher NT-pro-BNP (3108±4526 vs 2271±3637 pg/mL; p<0.0001). Despite this, over a mean follow-up period of 9±2 months, rates of all-cause hospitalisation (24% vs 44%; p<0.0001) and CV hospitalisation (3% vs 15%, p<0.0001) were significantly lower in the compliant group versus the non-compliant group, respectively. There was no significant difference in mortality rates (6% compliant group vs 8% non-compliant group; p=0.487).

CONCLUSIONS

Hospitalisation rates in patients with suspected HF and raised NT-pro-BNP were extremely high over a relatively short follow-up period. Patients reviewed in a specialist HF clinic had much higher NT-pro-BNP levels, suggesting they were at higher risk of adverse outcomes, yet also had significantly lower rates of all-cause and CV hospitalisation. Our findings support implementation of the relevant NICE guidelines for patients with suspected HF.

Drug therapies in chronic heart failure: a focus on reduced ejection fraction

There are multiple evidence-based drug treatments for chronic heart failure (HF), both disease-modifying agents and those for symptom control. The majority of the evidence base supports drugs used in HF with reduced left ventricular ejection fraction. The mainstay of disease modification involves manipulation of neurohormonal activation that occurs in HF. In addition to established angiotensin-converting enzyme inhibitors, beta blockers and mineralocorticoid receptor antagonists (MRAs), newer agents are now available such as the angiotensin receptor neprilysin inhibitors. Achieving the optimal drug regimen is complex and best performed by a specialist heart failure team. We aim to provide a comprehensive overview of contemporary drug therapies in chronic heart failure, as well as practical guidance for their use. There is a focus on treating patients with challenging comorbidities such as hypotension and chronic kidney disease (CKD), where a thorough understanding of drug therapy is essential. Multiple trials assessing the benefits of new therapies in HF, such as intravenous iron, are also ongoing.