Heart failure is a complex pathology with a high prevalence and there is already a significant number of multidisciplinary units led by specialists in cardiology or internal medicine, for its care; Based on this, the Spanish Society of Cardiology (SEC) and the Spanish Society of Internal Medicine (SEMI) promoted a survey to better understand the accredited heart failure units in the country.[1]
It should be noted that the Spanish Society of Cardiology accredits heart failure units that meet its quality standards and the Spanish Society of Internal Medicine has a program for Comprehensive Management Units for Patients with Heart Failure (UMIPIC).
Dr. Evelyn Santiago-Vacas
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“This is the first time that cardiology and internal medicine have come together; the different societies had carried out separate evaluations, but this collaboration had never been done. It is important because we are complementary and we need each other. The model we have here is not implemented in all countries, it is quite unique and I think it is very good,” lead cardiologist Dr. Evelyn Santiago-Vacas, from the Heart Failure Unit of the Germans Trias i Pujol Hospital in Barcelona, told Medscape in Spanish.
Survey results: high therapeutic compliance and day hospitals
The survey was sent to 110 heart failure units: 73 cardiology, accredited by SEC-Excellent, and 37 internal medicine, integrated into the program for Comprehensive Management Units for Patients with Heart Failure. The responses were anonymous and 67% and 92% participation was obtained, respectively.
The main members of the heart failure units were cardiologists plus internist plus specialized nurse (34.9%), in second place cardiologist plus specialized nurse (30.1%) and third internist plus specialized nurse (20.5%).
Units with a full-time nursing department make up 70% of the sample, with a nurse (most with specialized training in heart failure) assuming responsibilities, for example, participating in pharmacological titration in 63% of the units.
At the same time, almost all heart failure units (86.7%) have a day hospital where drugs can be administered intravenously.
In the sample, therapeutic compliance was very high, even with drugs that have shown a prognostic benefit in heart failure and have recently been included in the European guidelines. For example, the two most recent drug groups (neprilysin and angiotensin receptor inhibitor and sodium-glucose cotransporter type 2 inhibitors) are already used in all heart failure units. Sodium-glucose cotransporter type 2 inhibitors are started upon hospitalization in 67% of patients, a higher percentage than in those led by cardiology, which attend groups of patients who would have confirmed benefit.
“The high therapeutic compliance was surprising, especially since the guidelines and also the studies of these drugs were made public in August 2021,” said Dr. Santiago-Vacas.
The units that participated in this survey seem to be doing a good job. More than 80% make the first visit within 14 days of admission for heart failure, as recommended, and >60% have the flexibility to schedule visits based on patient needs. This great organizational effort means that 90% of heart failure units complete pharmacological titration within six months of the first visit and 45% in the first three months.
The main conclusion of the study authors is that both types of models (units led by cardiology or internal medicine) are complementary and necessary to be able to satisfactorily care for the broad clinical spectrum of patients with heart failure.
They are not all the same
As expected by the organizers, the profile of patients treated in heart failure units is very different from those of the program for Comprehensive Management Units for Patients with Heart Failure, the latter being older individuals with preserved left ventricular ejection fraction and a higher burden of comorbidity.
Some mixed units share characteristics more typical of cardiology and others are more similar to those of internal medicine. When compared with the non-mixed ones, therapeutic compliance was the same, but in the follow-up of visits and the administration of treatment, especially in the day hospital, the mixed ones were superior. “That is why we believe that a multidisciplinary model is better than that of monographic consultations,” said Dr. Santiago-Vacas.
When compared with previous studies, the authors found a clear evolution over time in the care of patients with heart failure in Spain. The availability of day hospitals, which went from 18% in 2007 to 92% at present, is a relevant change.
“There are more and more accredited units and more specialized nursing in heart failure that has more empowerment over the patient,” said the specialist.
Model to copy in Latin America?
Dr Jorge Thierer
Medscape in Spanish requested the opinion of Dr. Jorge Thierer, head of the CEMIC Heart Failure Unit and director of the Revista Argentina de Cardiología, who pointed out that in Latin America, due to a lack of data, the true prevalence of heart failure is unknown, nor is the number of patients treated by cardiologists and how many by primary care physicians, and the standardization and protocolization of heart failure treatment in specific units in Spain is more striking.
“The heart failure consensus that the Argentine Society of Cardiology (SAC) has just released addresses what a doctor can do in his office or what should be done in the context of hospitalization for heart failure, in which follow-up by specific teams of outpatients is standardized,” said the specialist who added that even though it may be seen as a trend, in Latin America there are still few heart failure units. “And we are far from having a standardization in the management of heart failure units. Very few centers, for example, have nursing staff specially dedicated to monitoring patients in outpatient treatment together with the doctor.”
Likewise, the specialist agreed that having a closer follow-up with protocolized behaviors that ensure better compliance with treatment guidelines and recording what is done to see where mistakes are made results in better evolution for patients. But that requires a certain level of organization, a greater number of people, and evaluating whether all the systems can cope with them. “The creation of heart failure units responds to the complexity of the pathology, to the need for frequent monitoring, imposes costs, but at the same time reduces them, because it ensures better treatment for patients, but it cannot be done everywhere with the same level of complexity,” he pointed out.
The physician sees the development of care units in a broader perspective. “The concept of a heart failure unit could also be expanded to other pathologies, to the intersection with other specialties. After all, heart failure is a disease that does not go alone, it is always accompanied by other pathologies. Multidisciplinarity is essential, with the participation of specialists from other branches of medicine and the growing understanding that this is not a heart disease, but rather a systemic one.”
In particular, Dr. Thierer does not consider it essential that the follow-up of all patients with heart failure be directed by a cardiologist. “Half of patients with preserved ejection fraction, predominantly older adults, do not die of the condition. An older adult with heart failure also has kidney failure, anemia, lung disease, cognitive impairment…a cardiologist doesn’t have to be the one to direct treatment for all of that. But it certainly shouldn’t be absent.”
Regarding the responsibility of the nursing team, he agreed on the importance of their training in a heart failure unit, even for telephone follow-up, but he considers that interpreting laboratory results and deciding what to do is something that a doctor should do. The system evolved, but it is not perfect
“A point to work on in Spanish heart failure units is the lack of coordination that exists with the primary care physician,” commented Dr. Santiago-Vacas. The survey revealed that only 1 in 4 of these model units (24%) maintain fluid communication with primary care and 29% acknowledge not having communication with it; 43% of the units acknowledge that less than 10% of patients are followed up jointly or referred to primary care.
The specialist accepted that there could be an important individual factor in the way of relating, but that there should be a relationship at the unit level promoted at the institutional level.
“The main thing is to understand that heart failure is a complex pathology with a high prevalence, with more and more patients, older, more comorbid, and that multidisciplinary work between cardiology and internal medicine together with the specialized internal nurse and contact with primary care should be the goal.”
The Spanish study continues. After this first phase, in which accredited units were convened, which therefore underwent audit by the societies, a second survey was launched aimed at heart failure monographic units (run either by cardiology or internal medicine) and those places where there are no accredited units. The third intended phase consists of advancing in the knowledge of primary care.
Follow Roxana Tabakman from Medscape in Spanish on Twitter @RoxanaTabakman.
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