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....................................................... 9 Multidisciplinary team management for the prevention and treatment of chronic heart failure

9.1 Prevention of heart failure

General advice about risk factors for the development of HF (see Supplementary Figure 1) and strategies to prevent HF early in the CV continuum are summarized in Table 10. It is widely recognized that, in addition to optimizing medical and device therapies for HF, attention should also be given to how HF care is delivered. The HFA of the ESC has issued several position papers that cover non-pharmacological management, discharge planning, and standards for delivering HF care.303305 It has also underscored the need for specialist HF cardiologists and specialist HF nurses to help provide care. Detailed curricula, to aid training of these, are available to be adapted for national implementation.306,307 This section focuses on areas where recommendations with an evidence level can be given: multidisciplinary team management, lifestyle advice, exercise training, follow-up, and monitoring.

9.2 Multidisciplinary management of

chronic heart failure 9.2.1 Models of care In order to reduce hospitalizations and mortality, earlier guidelines1 recommended the use of multidisciplinary HF management programmes (HF-MPs), which enable patients to have the correct investigations, an accurate diagnosis, appropriate evidence-based therapy, education, and suitable follow-up. The optimal implementation of a HF-MP requires a multidisciplinary team that is active along the whole HF trajectory; from onset, through critical events, periods of apparent stability, and its terminal stages.303 Since the 2016 guidelines, new studies have been published that underscore the need for HF-MPs and reveal more insights into how care can be delivered. A network meta-analysis including 53 randomized trials published in 2017, concluded that both disease-management clinics and home visits by nurses reduced all-cause mortality compared to usual care; home visits being most effective.308 An IPD meta-analysis of 20 studies, including 5624 patients, concluded that self-management interventions in HF patients improve outcomes despite heterogeneity in the intensity, content, and the personnel who deliver the interventions.309 HF-MPs vary in their components and can apply different service models, such as clinic-based approaches (in primary, secondary, or tertiary care), home-based programmes, case management, or hybrids of these. Components used in the services vary, e.g. some HF-MPs use telemonitoring that may be applied at a local, regional, or national level. No service model has been shown to be consistently superior to others.310 While home visits and HF clinics do reduce all-cause admissions and mortality, educational programmes, used alone, do not.308,309 HF-MPs should be patient-centred and take a holistic approach to the patient rather than focussing solely on HF; management of comorbid conditions, such as arrhythmias, hypertension, diabetes, renal dysfunction, and depression, improve patient well-being and self-management, leading to better outcomes.309,311 The organization of a HF-MP should be adapted to the healthcare system, available resources (infrastructure, facilities, staff, and finances), administrative policies, and tailored to the patient’s needs.

Many patients with HF would derive benefit from the early integration of a palliative and supportive approach within the care provided by all members of the HF multidisciplinary team.312,313 Palliative and supportive care should be thought about for all patients with HF, regardless of stage of their illness. Patients in the advanced stages and those considered for mechanical circulatory support (MCS) or heart transplantation should receive a palliative care consultation before such interventions as a matter of protocol (see section 10.2.4).

9.2.2 Characteristics and components of a heart failure management programme Clinical trials have included complex, bundled interventions, making it difficult to determine the efficiency and effectiveness of each specific component. Table 11 presents an overview of characteristics and components that are important to consider in a HF-MP.

9.3 Patient education, self-care and

lifestyle advice Adequate patient self-care is essential in the effective management of HF and allows patients to understand what is beneficial, and to agree to self-monitoring and management plans.319 HF patients who report more effective self-care have a better QOL, lower readmission rates, and reduced mortality.309 Misunderstandings, misconceptions, and lack of knowledge all contribute to insufficient self-care and therefore patient education is vital. Improving patients’ knowledge of their condition is fundamental for the development of self-care skills.304 Education to improve self-care should be tailored to the individual patient and based on, where available, scientific evidence or expert opinion. There is little evidence that specific lifestyle advice improves

Multidisciplinary interventions recommended for the management of chronic heart failure

Recommendations Classa Levelb

It is recommended that HF patients are enrolled in a multidisciplinary HF management programme to reduce the risk of HF hospitalization and mortality.309,314,315,316 I A Self-management strategies are recommended to reduce the risk of HF hospitalization and mortality.309 I A Either home-based and/or clinic-based programmes improve outcomes and are recommended to reduce the risk of HF hospitalization and mortality.310,317 I A Influenza and pneumococcal vaccinations should be considered in order to prevent HF hospitalizations.315,316 IIa B

HF = heart failure. aClass of recommendation. bLevel of evidence. ESC 2021

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