ABSTRACT
Background
Nurse-led multidisciplinary heart failure clinics (MDHFC) play an important role in patient care in developed countries due to proven benefits in mortality, hospitalization, and quality of life. However, there is limited evidence about the role of MDHFC in a limited resource setting.
Methods
Patients with HFrEF (n=89), were enrolled in a prospective longitudinal cohort from January 2018 to January 2019. Endpoints were collected at baseline and after 6 months of follow-up: 1) Quality of life using MLHFQ questionnaire 2) Medication adherence using MMAS Scale 8-item 3) Titration of heart failure medications 4) Self-care behavior using European Heart Failure Self-care behavior scale (EHFScBS) 5) Mortality and hospitalizations up to 12 months after.
Results
There was a reduction in the MLHFQ score from 66.5 (IQR 46,86) at baseline to 26 (IQR 13,45) at 6 months (p<0.001). NYHA functional class improved at 6 months (NYHA I: 41.9%, NYHA II: 39.5%, NYHA III: 17.2%) compared to baseline (NYHA I:20%, NYHA II:49%, NYHA III: 31%) (p<0.001). Medication adherence using the MMAS-8 improved in the score from 6 (IQR 4,7) at baseline to 7(IQR 6.25-8) (p:0.001) at 6 months. Up-titration of ACEi/ARB (25% vs 18 % at target dose) and BBs (25% vs 11% at target dose) was documented. After 6 months of follow-up, EHFScBS was applied showing a score of 18.5 (IQR:15,22). The mortality reported at 12 months of follow-up was 9.7% and hospitalizations were 44%.
Conclusion
A MDHFC is a feasible strategy to manage a heart failure clinic in a low-resource setting.
Graphical abstract
Graphical Abstract
KEYWORDS
1. INTRODUCTION
Heart Failure (HF) is a major public health problem associated with significant morbidity, mortality, and cost.
1
, 2
, 3
It is estimated that 64.3 million people worldwide suffer HF.Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063. Epub 2022 Apr 1. Erratum in: Circulation. 2022 May 3;145(18):e1033. PMID: 35363499.
4
Incidence varies widely among European countries and the USA from 1 to 9 cases per 1000 person-years.1
In Latin America, the estimated prevalence of HF is approximately 1% and the anticipated incidence is about 2 cases per 1000 person-year.5
Over the years there has been an increase in prevalence which combined with more costly medical treatments increases the economic burden of HF.6
, 7
, 8
In the USA, the total cost of HF care in 2020 was estimated to be 43.6 billion per year and in Latin America, 10.7 billion in 2015.7
,9
In contrast to the USA, Latin American countries have reduced gross income and lower total expenditure on health per capita. This constitutes a paradox considering that both HF and its risk factors are increasing in prevalence.5
,10
Therefore, new, and cost-effective strategies are essential for the prevention and management of HF in a low-resource setting.10
Nurse-led multidisciplinary heart failure clinics (MDHFC) have been an essential and innovative strategy for the management of patients with HF through individualized patient care with proven reduction of HF hospitalizations, mortality, improvement of quality of life (QoL), and self-care behavior.
11
, 12
, 13
, - Van Spall H.G.C.
- Rahman T.
- Mytton O.
- Ramasundarahettige C.
- Ibrahim Q.
- Kabali C.
- Coppens M.
- Brian Haynes R.
- Connolly S.
Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis.
Eur J Heart Fail. 2017 Nov; 19 (Epub 2017 Feb 24. PMID: 28233442): 1427-1443https://doi.org/10.1002/ejhf.765
14
Little is known about the impact of MDHFC on HF patients in developing countries, especially in a low-resource setting. Mendez et. al., reported an important benefit of the MDHFC in quality of life using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). 15
All together point towards the potential utility of this approach.Panama is a developing country considered to be a high-income nation by The World Bank. According to an analysis of the Health Financing Situation in Panama made by the Pan American Health Organization (PAHO)
16
, the public spending on healthcare arises to 7.6% of the PIB. However, the uneven wealth distribution particularly in the public setting plays a vital factor in the development of a low-income public health care system.Health Planning Department (DIPLAN). Ministry of Health. Analysis of the Health Financing Situation in Panama 2021. Pan American Health Association (PAHO). January 2022 [Internet] [cited on March 28th ,2023]. Available at: https://www.paho.org/es/documentos/analisis-situacion-financiamiento-salud-panama-2021
Panama's health care system is composed of three simultaneous organizations: Social Security (CSS), the Ministry of Health (MINSA), and private hospitals through private insurance. Every employed worker pays a percentage in taxes to CSS which gives them free access to all healthcare included in the CSS hospital network. However, healthcare is limited to the medications and specialists the network can provide. On the other hand, the MINSA network is mainly designed for the segment of the population that does not work formally and foreigners. In the MINSA networks patients pay a small percentage of the costs and the rest is subsidized by the government. Hospital Santo Tomas belongs to the MINSA network.
In addition, there is a shortage of physicians specialized in the management of patients with HF, thus limiting access to appropriate medical care and adequate access to HF medications. Taking those conditions into account MDHFC was implemented in The Hospital Santo Tomas to facilitate a close follow-up of patients with this condition and improve medication adherence.
Currently, there are no studies in Panama evaluating the population of patients with HF. Considering the above and in the absence of access to advanced costly therapies including heart transplantation, we sought to evaluate the impact of a Nurse-Led Multidisciplinary Heart Failure Clinic in a low-income resource setting as a potential strategy for the management of this clinical complex condition and aid in adherence and follow-up.
2. MATERIAL AND METHODS
This is a longitudinal cohort study designed to monitor essential clinical endpoints of a MDHFC program in a tertiary care public hospital such as Hospital Santo Tomas (HST). HST is the second-largest public hospital in Panama with 652 beds. It was opened in its current location in Panama City, Panama in 1924 and opened the MDHFC in 2016. This MDHFC is currently led by one full-time nurse Monday through Friday 7 am to 3 pm. The nurse is a heart failure specialist and has trained previously in another MDHFC in Costa Rica.
2.1 Participant selection
Patients with HF were enrolled in a registry between January 2018 and January 2019 after explaining the purpose of the study. The patients enrolled were selected based on the following inclusion criteria: a) Evidence of reduced left ventricular (LVEF≤ 40%) by echocardiography performed by the same experienced ecocardiographist b) Clinically stable patient with a new diagnosis of HF (NYHA class I-III) c) Age years d) Not being a patient in another HF clinic or previously participated in an education program. We excluded patients with severe psychiatric disease, dementia, moderate to severe cognitive deficits, and illiterate patients. To avoid potential selection bias and due to economic limitations, the registry only included those patients with a new diagnosis of HF found by the cardiologist and then referred to the MDHFC.
2.2 Clinical intervention description
Enrolled patients received intensive HF education, titration of medications, and social work evaluation together with a nutritional assessment in several sessions (at least once every 2 weeks) for the first three months. The HF education was led by the heart failure specialist nurse leading the clinic using pamphlets designed by the Panamanian Society of Cardiology and translated versions to Spanish designed for patients by the American Heart Association. Appropriate referrals to other specialists such as nutrition, psychiatry, and physical medicine and rehabilitation (PM&R) were provided as needed. The sessions included a 1:1 conversation with the patient and allotted time for questions and answers, with reinforcement in subsequent sessions. The patients were also given pamphlets to take home. Titration of medication included an increase in doses in each session to try to reach guideline-directed therapy recommended by the cardiologist or a decrease in doses due to medication intolerance.
This was followed by a maintenance phase of 3 months in which serial medical evaluations were performed focused on strengthening medication adherence, self-care, proper diet, and promoting healthy habits. These evaluations were performed by the heart failure specialist nurse and were done every month. Patients also met up with the cardiologist for follow-up every two to six months depending on the clinical condition of the patients or if changes in medication were needed due to intolerance or adverse effects. The heart failure specialist nurse had constant communication with the cardiologists regarding the patients enrolled. After 6 months, patients are seen by the nurse on the date of the follow-up appointment with the cardiologist.
Session time varies greatly, up to one hour with new patients and half an hour with follow-up appointments. Patients were grouped by their primary diagnosis into those with ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM). ICM included coronary artery disease and dilated cardiomyopathy due to myocardial infarction. NICM included dilated idiopathic, postpartum, familial, myocarditis-related, alcohol, viral, and drug-related cardiomyopathies.
2.3 Clinical endpoints measured
The following clinical endpoints were evaluated at baseline, before study enrollment, and after 6 months of follow-up: 1) QoL and functional status using the validated Spanish version of Minnesota Living with HF Questionnaire (MLHFQ) and the New York Heart Association (NYHA) Functional Class Assessment 2) Medication adherence using Spanish validated version of Morisky Medication Adherence Scale 8-item (MMAS-8).
17
3) Titration of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) dose equivalent to enalapril (see supplementary material for equivalent dose). Enalapril doses were categorized as low (), medium (), and high dose ().18
Titration of beta-blockers (BBs) dose equivalent to carvedilol. Carvedilol doses were categorized as low (), moderate (), and high dose ().19
4) Self-care behavior using Spanish validated version of European Heart Failure Self-care behavior scale (EHFScBS) was evaluated at 6 months of monitoring in MDHFC.5) A follow-up echocardiography was performed at 6 months after enrollment in the MDHFC to estimate the left ventricular ejection fraction (LVEF). Heart failure with recovered LVEF was defined according to a) Documentation of previous LVEF<40% at baseline b) 10% absolute improvement in LVEF and c) A second measurement of LVEF >40%.
20
6) Mortality and hospital admission were reported up to 12 months after enrolling in the study.Additionally, we attempted to collect blood pressure measurements and lipid profiles at baseline and 6 months; however, mainly due to economic limitations data was not included in the analysis. It is noteworthy to clarify that most of the patients enrolled were also on MRAs, however, it was not included in the final statistical analysis due to the abundant lack of data for the 6-month follow-up and few changes in doses. Also, a small subset of patients was on ARNI and SGLT2i. However, due to delays in regulatory approval and its high cost, these medications are not widely available in public hospitals such as Hospital Santo Tomas and thus we cannot draw conclusions from the small subset of patients who were on this medication.
MMAS-8 is an 8-item checklist-type validated scale to identify nonadherence The score on the scale is from 0 to 8, and higher scores correlate to better adherence to medication. EHFScBS is a 12-item validated scale to evaluate self-care behaviors. The score on the scale is from 12 to 60, and the lower values are those that indicate better self-care.
2.4 Statistics and ethics
The enrollment characteristics of this study were assessed with descriptive statistics, using proportions for categorical variables and medians with interquartile range (IQR) for continuous variables due to expected skewed distribution. Differences in patient characteristics according to the type of cardiomyopathy were assessed with the Pearson X2 test for categorical variables and the Mann-Whitney U test for continuous variables.
For paired quantitative data like MLHFQ score, LVEF, MMAS-8, and NT-ProBNP, Wilcoxon’s rank paired test was performed. For paired categorical data Mc-Nemar test was carried out. All estimates were reported using a 95% confidence interval and a P value of 0.05 was considered statistically significant. All analyses were performed using Stata version 14.0 (StataCorp LLC, Lakeway Drive, Tx). The rate of incomplete data was overall small (<5%).
The research protocol was approved by the Hospital Santo Tomas Bioethics committee and followed the principles established in the Declaration of Helsinki. All patients involved in the study were provided written informed consent to allow the use of their medical records and monitoring in the HF clinic.
3. RESULTS
A total of 89 patients were enrolled in the study. Out of these 89 patients, 81 completed a follow-up of at least 6 months (5 patients died before the 6-month assessment, and 3 were lost to follow-up). The patient's median age was 54 (IQR:45-61). NICM patients were slightly younger than those with ICM (52 years vs 55 years, p:0.003).
Baseline characteristics are represented in Table 1. Hypertension [70.4% (n=62)], obesity [40.4% (n=36)], dyslipidemia [39.3% (n=35)], and diabetes [34.8% (n=31)] were the most prevalent comorbidities.
Table 1Baseline characteristics of Patients with Heart Failure enrolled in the Nurse-led Multidisciplinary Heart Failure Clinic.
| Variable | General (n:89) | ICM (n:38) | NICM (n:51) | P value |
|---|---|---|---|---|
| Sex - Female - Male | 34 (38%) 55 (62%) | 12 (31.6%) 26 (68.4%) | 22 (43.1%) 29 (56.9%) | 0.267 |
| Age (years) | 54 (IQR 45-61) | 55 (IQR 46-60) | 52 (IQR 42-63) | 0.003* |
| Education Time (years) | 10 (IQR 7-12) | 12 (IQR 8-12) | 9 (IQR 7-12) | 0.248 |
| NYHA - NYHA I - NYHA II - NYHA III | 18 (20.3%) 44 (49.4%) 27 (30.3%) | 8 (21.1%) 20 (52.6%) 10 (26.3%) | 10 (19.6%) 24 (47.1%) 17 (33.3%) | 0.351 |
| Smoking | 24 (27.3%) | 14 (37.8%) | 10 (19.6%) | 0.071 |
| Hypertension | 62 (70.4%) | 28 (75.7%) | 35 (68.6%) | 0.404 |
| CAD | 20 (22.7%) | 20 (54%) | 0 (0%) | <0.001* |
| Diabetes | 31 (34.8%) | 18 (48.7%) | 13 (25.5%) | 0.025* |
| Obesity | 36 (40.4%) | 19 (51.4%) | 17 (33.3%) | 0.090 |
| Dyslipidemia | 35 (39.3%) | 20 (52.6%) | 15 (29.4%) | 0.034* |
| Cerebrovascular disease | 8 (8.9%) | 4 (10.8%) | 4 (7.84%) | 0.633 |
| Atrial Fibrillation | 13 (14.6%) | 5 (13.16%) | 8 (16 %) | 0.710 |
| NT-ProBNP (pg/mL) | 1067(IQR 216.5-3583) | 433.5 (IQR 189-3506) | 1297 (IQR 367-3855) | 0.248 |
| LVEF | 30% (IQR 25%-36%) | 21% (IQR 20%-30%) | 35% (IQR 25%-36%) | 0.475 |
| Morisky 8-item | 6 (IQR 4-7) | 6 (IQR 4-7) | 6 (IQR 4-7) | 0.853 |
| MLHFQ | 66.5 (46-86) | 59 (IQR 46-82) | 67 (IQR 39-88) | 0.747 |
| Beta-Blocker use | 84 (97.6%) | 35 (97.2%) | 47 (97.9%) | 0.532 |
| ACEi/ARB use | 76 (84%) | 33 (86%) | 42 (84%) | 0.431 |
Table 1 IQR: interquartile range, NICM: Non-Ischemic cardiomyopathy, ICM: Ischemic cardiomyopathy, NYHA: New York Heart Association Functional Status, CAD: coronary artery disease, LVEF: Left Ventricular Ejection Fraction, MLHFQ: Minnesota Living with Heart Failure Questionnaire. N-terminal (NT)-pro hormone BNP (NT-proBNP). Education time refers to the number of years spent in an academic institution including elementary school, junior/high school, and university., * Statistically significant.
3.1 Clinical endpoints results
1) In the assessment of QoL, there was a reduction in the MLHFQ score from 66.5 (IQR 46,86) at baseline to 26 (IQR 13,45) at 6 months (p<0.001). These reductions were notable in both dimensions measured, physical and emotional (Table 2). Similarly, NYHA functional class improved at 6 months (NYHA I: 41.9%, NYHA II: 39.5%, NYHA III: 17.2%) compared to baseline (NYHA I:20%, NYHA II:49%, NYHA III: 31%) (p<0.001). (Table 2).
Table 2Clinical endpoints of patients with Heart Failure admitted to the Nurse-led Multidisciplinary Heart Failure Clinic.
| Variable | General | ICM | NICM | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Baseline | 6 months | P | Baseline | 6 months | P | Baseline | 6 months | p | |
| NYHA NYHA I NYHA II NYHA III NYHA IV | 18 (20%) 44 (49%) 27 (31%) 0 | 34 (41.9%) 32 (39.5%) 14 (17.2%) 1 (1.2%) | <0.001* | 8 (21.1%) 20(52.6%) 10 (26.3%) 0 | 17(48.6%) 11(31.4%) 6 (17.1%) 1 (2.9%) | <0.0001* | 10 (19.6%) 24(47.1%) 17 (33.3%) 0 | 17(36.4%) 21(45.6%) 8 (17.4%) 0 | <0.001* |
| LVEF | 30%(IQR:25%-36%) | 40%(IQR:33%-45%) | <0.001* | 21%(IQR:20%-30%) | 40%(IQR:32%-46%) | <0.001* | 35%(IQR:25%-36%) | 39%(IQR:33%-44%) | <0.001* |
| MLHFQ Physical Emotional | 66.5(IQR:46-86) 30(IQR:21-36) 12(IQR:6-18) | 26 (IQR:13-45) 10 (IQR 2-16) 5 (IQR 2,8) | <0.001* <0.001* <0.001* | 59 (IQR 46-82) 29 (IQR:18-35) 11(IQR:5-19) | 24 (IQR: 12.5-39.5) 9 (IQR: 2-15) 4 (IQR: 1,7) | <0.001* <0.003* <0.004* | 67 (IQR 39-88) 31 (IQR 22-37) 14 (IQR: 7-20) | 27 (IQR 14-47) 11 (IQR 3-17) 6 (IQR 3-9) | <0.001* 0.001* 0.002* |
| MMAS-8 | 6 (IQR 4-7) | 7 (IQR 6-8) | <0.001* | 6 (IQR 4-7) | 7 (IQR 6.25-8) | <0.001* | 6 (IQR 4-7) | 7 (IQR 6-8) | 0.009* |
| NTProBNP (pg/mL) | 1067(IQR:216.5-3583) | 553 (IQR:166-2078) | 0.712 | 433.5(IQR:189-3506) | 344.5(IQR:118-649) | 0.585 | 1297(IQR:367-3855) | 990 (IQR 206-2260) | 0.340 |
| BBs use | 84 (94.3%) | 75(90.3%) | 0.042* | 35 (97.2%) | 32 (94%) | 0.002* | 47 (97.9%) | 43 (95%) | 0.067 |
| ACEi/ARB use | 76 (84%) | 68 (82%) | 0.031* | 33 (86%) | 28 (84%) | 0.043* | 42 (84%) | 40 (88%) | 0.074 |
Table 2 IQR: Interquartile range, NICM: Non-Ischemic cardiomyopathy, ICM: Ischemic cardiomyopathy, NYHA: New York Heart Association Functional Status, LVEF: Left Ventricular Ejection Fraction, MLHFQ: Minnesota Living with Heart Failure Questionnaire, MMAS-8: Morisky Medication Adherence Scale 8-item, BBs: beta-blockers. * Statistically significant (p<0.05).
2) Regarding medication adherence using the Morisky Medication Adherence Scale 8-item there was also an improvement in the score from 6 at baseline (IQR 4,7) to 7(IQR 6.25-8) (p:0.001) at 6 months. (Table 2) In this scale, if the patient scores higher, they are evaluated as more adherent. We show improved adherence in this group of patients provided by the MDHFC.
3)Up-titration of ACEi or ARB (equivalent to enalapril dose) and BBs (equivalent to carvedilol dose) were documented (Table 3); there was a larger proportion of patients close to target doses stratified by NYHA functional status at 6 months (25% at target dose), in contrast with baseline proportion (18% at target dose) (P:0.034). Similarly, BBs were up-titrated closer to target doses at 6 months (25% at target dose) in comparison to baseline proportion (11% at target dose) (p:0.0021).
Table 3Up-titration of ACEi or ARB (equivalent to enalapril dose) and BBs (equivalent to carvedilol dose) according to NYHA functional status.
| NYHA functional status | ACEi/ARB dose (equivalent to enalapril dose) baseline (n=89) | ACEi/ARB dose (equivalent to enalapril dose) -at 6 months (n=81) | BBs dose (equivalent to carvedilol dose)- baseline (n=89) | BBs dose (equivalent to carvedilol dose)- at 6 months (n=81) |
|---|---|---|---|---|
| NYHA I | N=18 | N=34 | N=18 | N=34 |
| -low dose | 4 (22%) | 6 (18%) | 8 (44%) | 3 (9%) |
| -medium dose | 10 (56%) | 19 (55%) | 8 (44%) | 26 (76%) |
| -high dose | 2 (11%) | 5 (15%) | 1 (6%) | 3 (9%) |
| NYHA II | N=44 | N=32 | N=44 | N=32 |
| -low dose | 11(24%) | 2 (6%) | 13 (29%) | 7 (22%) |
| -medium dose | 23 (53%) | 24 (74%) | 28 (64%) | 21 (66%) |
| -high dose | 3 (7%) | 3 (10%) | 2 (5%) | 2 (6%) |
| NYHA III | N=27 | N=15 | N=27 | N=15 |
| -low dose | 1 (4%) | 1 (6%) | 11 (42%) | 2 (13%) |
| -medium dose | 19 (70%) | 11 (76%) | 16 (58%) | 11 (74%) |
| -high dose | 2(7%) | 0 (0%) | 0 (0%) | 2 (13%) |
Table 3. NYHA: New York Heart Association Functional Status, ACEi: Angiotensin Converting Enzyme Inhibitors, ARB: Angiotensin receptor blockers, BBs: beta-blockers. Low dose of enalapril corresponds to <= 5mg/day, medium dose of enalapril corresponds to >5 to <20 mg/day, high dose of enalapril corresponds to >=20 mg/day. Low dose of carvedilol corresponds to <=12.5 mg/day, medium dose of carvedilol corresponds to >12.5 to <50 mg/day, high dose of carvedilol corresponds to >=50 mg/day.
4)After 6 months of follow-up EHFScBS was applied to show a score of 18.5 (IQR:15,22). (Table 2).
5)Among the patients who completed the 6 months follow-up, LVEF improved to 40% (IQR:33%,45%) compared to baseline LVEF: 30% (IQR:25%,36%) (p:0.001). In total 23.4% (n:19) of patients fulfilled the criteria for recovered LVEF.
6)The mortality reported in the MDHFC at 12 months of follow-up was 9.7% (9/89). Of the 9 patients that died, the median time of mortality was (126 days, IQR: 37 days- 217 days), among these patients, 5 died of complications of acute heart failure and 4 were reported as sudden death. Regarding hospitalizations, up to 44% of patients enrolled required at least one hospitalization due to HF after 1-year follow-up.
4. DISCUSSION
The present study assessed the effect of a nurse-led MDHFC in patients with heart failure in a low-resource setting of a Latin American public healthcare system. This intervention positively impacted the quality of life, medication adherence, appropriate up-titration of heart failure medication, and improvement in baseline LVEF in this group of patients. These translate into enhanced and effective patient care using the resources available.
In our study, most patients enrolled were middle-aged adults with NICM, and a high prevalence of hypertension, diabetes, and obesity. Similar epidemiological research also describes a high prevalence of HF in middle-aged adults related to a high prevalence of comorbidities such as hypertension and obesity.
21
,22
In Panama, hypertension, diabetes, and obesity are among the most common comorbidities in national-based registries with a reported prevalence of 29.6%, 9.5%, and 27.1% respectively.
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, 24
, 25
In addition, this population has important disability-adjusted life years (DALYs), as high as 21.7 years of life in men and 24.5 years-life in women among 50 to 59 years.7
,21
,26
,27
Focused studies are necessary to determine the extent these risk factors may have in the burden of HF in Panama.Regarding the quality of life, there have been previous studies reporting the benefit of heart failure clinics in QoL.
14
,28
,29
From the different types of instruments used to assess the quality of life in patients with HF, we choose MLHFQ. This instrument was applied in a previous study in Latin America, has a simple structure, and is easy to administer to patients.Jaarsma T, Hill L, Bayes-Genis A, La Rocca HB, Castiello T, Čelutkienė J, Marques-Sule E, Plymen CM, Piper SE, Riegel B, Rutten FH, Ben Gal T, Bauersachs J, Coats AJS, Chioncel O, Lopatin Y, Lund LH, Lainscak M, Moura B, Mullens W, Piepoli MF, Rosano G, Seferovic P, Strömberg A. Self-care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2021 Jan;23(1):157-174. doi: 10.1002/ejhf.2008. Epub 2020 Oct 20. PMID: 32945600; PMCID: PMC8048442.
30
Our study demonstrated a reduction of the general score of 40.5 points, a physical score of 20, and an emotional score of 7 from baseline at 6 months follow-up. A study in Mexico reported a reduction of 19 points in the general score.15
This result could be related to better adherence, appropriate titration of medications, and better self-care achieved in the MDHFC.Beyond QoL, up-titration of BBs and ACEi to a target dose was achieved in a few patients. According to the latest HF guidelines from ACC/AHA 2022 the four-pillar medication strategy includes the use of BBs and ACEi up titrated to an optimal dose upon tolerance. In our study, approximately 33% of patients required an increase in their dose of BBs, and 17% increased their dose of ACEi. The CHAMP-HF registry showed in clinical settings, that few patients were receiving the target dose of ACEi/ARB (17%) and BBs (28%), mainly due to medication intolerance.
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Expert opinion suggests some benefits in mortality even with low doses, though clinical trials were generally not designed to determine whether the benefits were dose-related.32
- Atherton J.J.
Australia D of C Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia S of M University of Queensland, Brisbane, Queensland, Hickey A, Australia AHF and CTU The Prince Charles Hospital, Brisbane, Queensland,. Expert Comment: Is Medication Titration in Heart Failure too Complex?.
Cardiac Fail Rev. 2017; 03: 25
In our study, the main limitation of medication up-titration was medication intolerance as we can evidence in our comparison data regarding BBs and ACEi/ARB use during follow-up (Table 1). Despite the fact we could not achieve the target doses according to guidelines in most patients there was an improvement in NYHA functional status, LVEF, and QoL. We hypothesize that in clinical practice the multidisciplinary approach in self-care, education, titration, and medication adherence is the real value of an MDHFC. Therefore, applying this approach to manage this complex condition is an effective method.
Regarding hospitalization and mortality, we observed high rates: close to 44% for hospitalization and close to 10% for mortality at 1 year of follow-up; higher than reported by other clinics.
12
,14
,28
. In Canada, an MDHFC showed a benefit in mortality (HR:0.69, NNT:16) and readmissions (HR:0.27, NNT:4), however, their population tends to be older compared to our population.14
Additionally, in our clinic we have limited access to advanced therapies for patients with HF including resynchronization therapy, heart transplantation, and left ventricular assist device limiting the management in advanced stages. The authors hypothesize that the absence of these advanced devices and the absence of medications such as sacubitril-valsartan and iSGLT2 (which have proven mortality and hospital readmission rate benefits) may impact the ability to adequately control the symptoms and the progression of the disease. Another plausible explanation for the higher mortality and readmission rate shown in this clinic could be associated with the high prevalence of other comorbidities such as diabetes, atrial fibrillation, cerebrovascular disease, and hypertension predisposing different cardiovascular outcomes or heart failure decompensation.This study represents the first cohort registry assessing the quality of life and impact of a nurse-led multidisciplinary Heart Failure Clinic in Panama. It also highlights the utmost relevance of nurses in achieving high-quality care for complex patients such as heart failure patients, even more in developing countries such as Panama.
4.1 Conclusions
A Nurse-led multidisciplinary Heart Failure Clinic is a feasible strategy to manage heart failure clinics in a low-resource setting. Such a comprehensive and structured approach seems to be associated with significant improvement in quality of life, medication adherence, up-titration of medication to target dose, and possible improvement in LVEF from baseline. These documented benefits might have an impact on the clinical management of a patient with heart failure and reduced ejection fraction in a limited resource setting.
4.2 Limitations
Among the limitations, we can highlight that as a descriptive type of research, the lack of a control group only allows us to hypothesize a correlation with the positive clinical endpoints shown. Also, the relatively small number of patients enrolled, and short follow-up (6 months only), limit the amount of sustained benefit regarding the quality of life, medication adherence, and up-titration we can attribute to the MDHFC and not just medication. More studies with higher statistical power such as randomized clinical trials are necessary to establish a real benefit in mortality and hospitalization, particularly in the younger population.
Another limitation applies to the type of patients, as this study included only newly diagnosed HFrEF patients by economic and human resource shortages. There are plans to expand the benefit population to chronic HF patients (both HFrEF and HFpEF).
The authors also recognize that due to the cost and low availability of MRAs, ARNI, and SGLTi in Panama’s health public system, the data regarding the use and experience with these medications were not included in the statistical analysis.
Uncited reference
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.5. ACKNOWLEDGMENTS
Data availability statement
Raw data were generated at HST Heart Failure Clinic. Derived data supporting the findings of this study are available from the corresponding author HB on request.
Funding
This study was funded by donations to the Hospital Santo Tomas and The Panamanian Society of Cardiology.
Competing interests
The authors have no relevant financial or non-financial interests to disclose
Author contribution
Harold Bravo, Julio Zuñiga, Cesar Cardenas, Eyleen Gonzalez, Edna Nichols, Gabriel Frago, and Alexander Romero conceptualized this project. HB, JZ, CC, EN, GF, and AL participated in the study conduct, data collection, and data analyses. The first draft of the manuscript was written by Julio Zuñiga and all authors commented on previous versions of the manuscript. Each author read and approved the final manuscript.
Supplementary Material
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Article info
Publication history
Accepted:
April 11,
2023
Received in revised form:
April 11,
2023
Received:
January 10,
2023
Publication stage
In Press Journal Pre-ProofFootnotes
cSanto Tomas Hospital. Panama City, Panama
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© 2023 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.
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