community heart failure service to improve heart failure care for people of Makkah.

1. .
Community Heart Failure
Services
Holy Makkah.
CHFS
Community Heart Failure Service
Asadullah Khan Soomro
Adult Cardiologist
King Abdullah Medical City Holy Makkah
Email: hssbasadsoomro@gmail.com

2. CHFS
Introduction
Heart Failure is a global pandemic ,affecting 64 million
people world wide .
Approximately 60-70% of HF patients are in stage A &
stage B ( Asymptomatic phase ).
Cardiology Community all over the world has not given
enough attention to prevent pre- HF from turning in to stage
C and advanced stage D heart Failure indeed.

3. CHFS
Introduction
All Heart Failure stakeholders have focused on symptomatic
Stage C & Stage D heart failure syndromes , which is a burn
out phase ,very expensive and not affordable to Public &
private health care systems indeed.
77% of the budget is spent on HF admission and
readmission Syndromes and unfortunately we are not
doing enough to overcome this issue.

4. CHFS
Family Physicians Role
Family physicians are not only stakeholders but gatekeepers
indeed.
We have not properly utilized the talents of family physicians
in prevention of heart failure at different stages .
There is a communication gape, and cardiology /heart failure
community has never bridge this gap, to educate them and utilize
their services in prevention of symptomatic HF at stage A & stage B (
asymptomatic phase ) ,and prevention of HF admission and
readmission syndromes.

5. A
&
B
56
%
C
D
HF
Stage
Code

6. Advanced
HF Stage D
Requiring
Special
Intervention.
Stage C
HF
Structural
disease with
( new
onset/ADCHF)
Symptoms
Stage
B HF
Structural
Heart Defects
Asymptomatic
Stage
A HF
With Risk
Factors
Asymptomatic
Heart Failure ( Step – Ladder )
Stage A & B ( Green ) Asymptomatic phase ( Community HF )
Stage C ( Orange ) Symptomatic phase ,de – novo /ADCHF phase
Stage D ( Red ) Advanced HF ,”Complex disease ,Complex therapy “
77%
( first
admission &
readmissions )

7. Ir Inte –hospital heart failure
Model of Care
“ Makkah Healthcare Cluster “
Model 1, Community Heart Failure Clinics
Heart failure service with only ,out patient clinic capability
Admission
Model 2
Heart Failure service with OPD
emergency and in patient
capability
Model 3Advanced Heart
Failure service
With Intervention, LVAD and
Cardiac transplant Capability

8. Model of Heart Failure Programme
HEART FAILURE CLINICAL CARE PROGRAME ( CCPC )
RAHFC
( RAPID ACCESS HEART FAILURE CLINIC )
“Goal is same Day “
One stop fast track heart referral from, PHC/ER to “Best
Care “ when ever and where ever requires.
( Cardio-Oncology & Cardio-obstetric services).
IN PATIENT
HEART FAILURE
CARE
COMMUNITY
HEART FAILURE
CARE
OUT PATIENT
HEART FAILURE
CARE
EMERGENCY
HEART FAILURE
CARE
Regular / Virtual
Heart Failure
Clinic
Post Discharge
Heart failure &
Cardiac Rehabilitation
Clinic
Nurse Led
Multi disciplinary
Heart Failure Clinic
Advanced
Heart Failure Clinic
4
2
1
3

9. 7 Stakeholders of Heart Failure
Programme & Network.
Key to success is 7 star HF education , education & education indeed “
1)
Patient Education
2) Family &
family Friends
Education
3) Paramedical
Personnel
Education
4) Physician /
medical students
Education
5) Payer organizations
Insurance Companies
Education
6) Admin directors
Policy Makers
Education
7)Pharmaceutical/ Devices and cardiac technological industry Education

10. CHFS
Family Physicians Role
How Family physicians can help in prevention of heart
failure , “ Doable & less costly “ ?
1) For 5 star HF service , & give them 7 star HF education
,Education and Education.
2) Give them ownership as part of main stakeholders.
3) Prevention and screening of heart failure at Stage A &
Stage B according to local facilities ( Follow models of care )
4) Involve them in prevention of ist hospitalization ( Via RAHFC )
and recurrent hospitalization ( Via PDHFC post discharge
early follow up and fix up HF clinic appointment 7 to 14th day ) .

11. Role of Community HF Clinic in Stage A HF
S
T
A
G
E
A
HF risk factors , Like Hypertension
• Multi system atherosclerosis * Drug Addicts ( Captagon, Alcohol & Hashish )
• Diabetes mellitus
• Metabolic syndrome or obesity * Connective tissue disorders
• Chronic renal failure
• Prolonged intake of cardiotoxic drugs
• Familiarity of cardiomyopathy .
Role of Family Physician
Identification of patients with risk
factors as mentioned above
◦ Non-pharmacological control of risk
factors (e.g. promoting physical
activity, weight monitoring ,control
Captagon, alcohol consumption)
◦ Setting and dose titration of
medication
◦ Clinical and instrumental follow-up
Community Group heart
failure education for patients
and their families, in
particular oriented to the
promotion of healthy
lifestyles, proper nutrition
and to the adherence of
pharmacological
and non-pharmacological
therapeutic prescription .
Community HF specialist
Counselling for patients
with problems
inadequately controlled
by first-level
interventions.
Role of HF Nurse Educater Role of Community HF specialist

12. Role of Community HF Clinic in Stage B HF
S
T
A
G
E
B
Stage B heart failure is characterized by structural heart defects , but still in asymptomatic phase.
Role of Family Physician
1) Echocardiographic diagnosis of
structural heart disease that was not
documented before .
2) patient with previous myocardial
infarction;
3) patient with mild to moderate
valvular heart disease.
4) Uncorrected grown up CHD
setting and adjustment of
5) Familial DCM
follow up, according to the specialist
recommendation,
Endocarditis prophylaxis.
Heart failure education
(patient/family) oriented to the
promotion of healthy lifestyles and
nutrition and pharmacological and
non-pharmacological therapeutic
adherence;
• education of the patient to the
self-control of blood pressure , body
weight;
• periodic evaluation of DM control;
• reporting to the family physician
(GP) with relevant issues and
collaboration for the diagnostic and
therapeutic management;
• opening and updating the
computerised clinic medical record.
In this stage other resources can be
activated (e.g. anti-smoking centres,
gyms ) in order to better control the
risk factors.
1) Diagnostic/therapeutic
confirmation of structural heart
disease;
2) Augmentation of clinical and
technological follow-up, in
agreement with the family physician;
consulting for issues not adequately
controlled by the first level
interventions;
3) indication for hospitalisation for
screening of the causes of myocardial
damage/evaluation of any indications
in non-pharmacological strategies
(revascularisation, correction of valve
disorders, device implant);
4) If all is good , no need for
intervention, asyptomatic,
Continue follow up and adjust
medications.
Role of HF Nurse Educater Role of Community HF specialist

13. Role of Community HF Clinic in Stage C HF
S
T
A
G
E
C
Stage C heart failure is characterized by structural heart defects symptoms of heart failure.
Role of Family Physician
1) clinical evaluation based on sign &
symptoms of HF and request for EKG, X-
ray / Routine laboratory test including
BNP/Pro-BNP.
2) If new onset HF, need specialist
referral for diagnostic confirmation;
( RAHFC if mild to moderate symptoms )
hospitalisation if severely symptomatic
when indicated;
3) Aetiological and precipitating factors
identification and prognostic
stratification;
4) Up gradation of clinical change in
electronic medical record .
4) Review Post discharge summary and
early follow up appointment in both
de-novo and ADCHF patients.
Heart failure education
(patient/family) oriented to the
promotion of healthy lifestyles and
nutrition and pharmacological and
non-pharmacological therapeutic
adherence;
• education of the patient to the
self-control of blood pressure , body
weight;
• periodic evaluation of DM control;
• reporting to the family physician
(GP) with relevant issues and
collaboration for the diagnostic and
therapeutic management;
• opening and updating the
computerised clinic medical record.
In this stage other resources can be
activated (e.g. anti-smoking centres,
gyms ) in order to better control the
risk factors.
1) Review clinical, impression of
family physician (echocardiography)
and laboratory evaluation for
confirmation/exclusion of the
diagnosis of symptomatic HF;
2) Aetiological identification ,
precipitating/ favouring factors and
prognostic stratification;
3) Adjustment of drug therapy;
clinical review and follow up with
family physician after discharge from
hospital ;
3) programming non-pharmacological
therapeutic procedures (e.g.
implantable devices, such as AICD,
CRT-P, CRT-D);
4) intervention in case of clinical
worsening without prompt
response to therapy or to the
appearance of complications.
Role of HF Nurse Educater Role of Community HF specialist

14. Role of Community HF Clinic in Stage D HF
S
T
A
G
E
D
Stage D is characterized by patients suffering from HF with frequent exacerbations despite
maximal medical therapy, which may require, in highly selected cases, specialized treatments such
as mechanical support to the circulation, fluid removal procedures, continuous inotropic infusions
and heart transplant. In certain cases, the patient benefits from a palliative care program
(integrated home assistance &hospice).
Role of Family Physician
1) Role of family physicians is limited ,because
most of these patients spent time in either ED
or inpatient, however ,we should be oriented
their need like bed arrangement in hospital
when indicated.
2) Adjustment of drug therapy based on
therapeutic needs of individual patient.
3)Clinical & lab follow-up based on the clinical
characteristics of the individual patient, in
agreement with the community HF specialist.
4) Early diagnosis of aggravations of heart
failure conditions with identification of
precipitating factors
5) Evaluation and control of co-morbidities
1) Periodic evaluation of the
parameters (e.g. pulse blood pressure,
body weight monitoring & O2 sat)
◦ Individual health education of the
patient and his family, in particular
verification of patient’s adherence
and persistence to the therapeutic
drug prescription, worsening of
symptoms
2) Telephone contact (from daily to
weekly) for information on taking the
drugs, patient’s subjective symptoms,
3) Ability to perform daily activities,
changes in the quality of sleep,
changes in body weight, onset of
intercurrent diseases./ Infections
Vaccinations.
Review polans of family physician ,need of
hospitalization if indicated
◦ Recognition of aggravation of heart failure
conditions with identification of precipitating
factors .
◦ Review drug therapy based on needs of
individual patient .
◦ Clinical and Lab follow-up based on the clinical
characteristics of the individual patient, in
agreement with family physician.
◦ Intervention in case of clinical worsening
without prompt response to therapy or any
complications
◦ Indication for AICD (automatic implantable
cardioverter defibrillator) CRT,MV clip &
LVAD/transplant.
◦ Indication to ultrafiltration
◦ Home access on request of the family
physician.
Role of HF Nurse Educater Role of Community HF specialist

15. CHFS
Why Community HF service is necessary .
Holy Makkah cluster has created an opportunity for heart
failure network (Grade 1 to Grade 111 HF services ( see Fig 1).
After the re-activation of KAMC heart failure clinic in
October 2018, we registered around 993 patients at this
prestigious clinic and around 330 patients, who fulfilled
criteria are on sacubitril ( Entresto) until June 2021 172 (
52.1%) patients are on target dose of 200 mg bid
( highest in Makkah region).

16. CHFS
Why Community HF service is necessary .
Since majority of patients live with HF as a chronic disease
and follow at outpatient clinics, many of them are
compensated on GDMT & fulfill the dispose criteria to
follow in community at primary/secondary care settings. To
creat opportunities for new and advanced deserving
HF patients, we need to formulate certain strategies for
health care providers in community who face many
challenges, Some of the key gaps include, the following:

17. CHFS
Real world Gaps &
Barriers at community level .
1. Small/solo primary care practices may not have the capacity to meet the
needs of HF patients with complexties and multiple co - morbidities;
2. Primary care community physicians are not informed/ have knowledge
gaps regarding clinical best practices for early diagnosis and even right
patient referral at right time, hence many HF patients do not receive guide
line directed Heart Failure therapies at right time .
3. Inter referral criteria from model 1 and 11 health care services to KAMC ( model 111 )
HF clinics and from KAMC to model 1 & 11 for Heart Failure patients are not standardized.
Even intra departmental consultations amongst general cardiologist / internal medicine
physicians to heart failure cardiologist face lot of communication gaps.

18. CHFS
Real world Gaps &
Barriers at community level .
4) Community care ( Primary/secondary) physicians need awareness and
education to refer ( friendly referral form ) mild to moderate / suspected
heart failure patients at KAMC novel rapid access heart failure clinic
(RAHFC ) at early stage before development of acute heart failure to
visit emergency for admission ( most deadly and costly affair ). Although
with the simple, and less costly efforts this acute phase is
preventable in many of the HF patients. .
5) Some HF patients do not have a registered files at community HF service
6. Wait times to access specialty HF clinics at KAMC are not measured, but we
believe are unacceptably long;

19. Do we need Community Heart Failure service??
Why and What are the challenges in establishing
Community HF care in Makkah region .
7. Models of HF care ( at primary & secondary Grade 1 & 11 ) vary
across the Makkah region. Heart failure education amongst
patients, families health care workers and policy makers
/Payer organizations are not up to dated.
8. Because of these imminent gaps there is high proportion of HF
emergency department visits ( uncountable), and hospital
readmissions within 30 to 60 days
( vulnerable phase ) of discharge, with readmission rates ranging
from 23% to 50%; (in different studies).

20. Do we need Community Heart Failure service??
Why and What are the challenges in establishing
Community HF care in Makkah region .
9. Most of the HF patients during transitional phase
after discharge are not evaluated by a HF cardiologist or
community HF physicians within 30 days of discharge,
because of this gape, patients repeatedly visits
emergency departments of different hospitals
and are inappropriately readmitted and
prematurely discharged, and this unending cycle
goes on and on.

21. Do we need Community Heart Failure service??
Why and What are the challenges in establishing
Community HF care in Makkah region .
10. Long Term Care of chronic HF patients are
usually residents around holy Makkah, and are
high users of Emergency department, because of
communication gap at all level of care ,which can be
improved through heart failure education and self
care . Despite improvement in heart failure services yet
many have no or fragmented access to evidence
based recommended therapies;

22. Do we need Community Heart Failure service??
Why and What are the challenges in establishing
Community HF care in Makkah region .
11. There is no cohesive strategy for the care of end-stage D Heart
Failure / and transition from stage C to D, therefore many
patients do not receive palliative care/ end of life care; ( DNR )
12. The model of heart failure( Fig 11) care is fragmented at all
levels, with insufficient emphasis on chronic disease prevention
and management ( Stage A & B HF before symptoms ) ,
including Heart failure awareness & education .
In this regard community physicians play a key role and ,
we believe their services are underutilized.

23. Do we need Community Heart Failure service??
Why and What are the challenges in establishing
Community HF care in Makkah region .
13. Last not the least, the cost associated with
stage C & D HF in terms of admission and
readmission is rampant, ( 77 % on
hospitalization ) and is not affordable to
patients ,insurance companies , organizations
and ministeries indeed. Nothing is free in the world
some body has to pay the cost of every thing .

24. Conclusion
In Heart Failure world ,we are facing with these
Tigers and Elephant heart with heterogeneous
prognosis.
We spent tons of money on care of heart failure ,yet
our services are Zigzag and fragmented.
We need to review our problem, and work on
organized care of heart failure for better outcome.

25. Conclusion
“ Zigzag/Disorganized”

26. THANK YOU
Living Longer, Living Well