ZA Bhutto Combind HF program updated.pptx

Shaheed Zulfiqar Ali Bhutto
First Multidisciplinary Value based Heart Failure
Program & network Sindh Pakistan.
This Unique manual is dedicated to Shaheed Z A Bhutto
Building
Heart Failure Program
to improve heart
failure services in
Sindh , Pakistan
Dr Asadullah Khan Soomro
MBBS , Diploma Cardiology ,Royal Brompton National Heart & Lung Institute University of London
Adult Cardiologist & Heart Failure Specialist , Altamash General Hospital Clifton block 1 Karachi Pakistan
Email , hssbasadsoomro@gmail.com : Mobile 0092 302 2308718

“GDMT Shift from inpatient to ambulatory outpatient Setting “
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Prevent

Heart failure (HF) is a complex clinical syndrome and one of the future’s largest challenges all over the world and
in Pakistan indeed . HF Pandemic is a warning for all HF stakeholders . Its an extremely , heterogeneous , Costly &
deadly syndrome . There are three burning issues in Heart Failure world , first mortality ( death & disabilities ) 2nd
morbidity ( quality of life ) and last not the least enormous cost of HF treatment because of prolonged & recurrent
hospitalizations .
Cost is rampant , not only for out of pocket paying patients but for healthcare systems and providers indeed .
In > 50% HF patients , atherothrombotic coronary artery syndromes ( CAD /MI ) with LV systolic
dysfunction , is main cause of ischemic heart failure in most of the low income countries ,including Pakistan
indeed . Ischemic HF syndromes & their risk factors like hypertension ,diabetes , tobacco products/illicit drugs are
responsible for extraordinary expenditure .
Primary PCI in acute MI is fantastic step in Pakistan to salvage myocardial damage ,but at the cost
of millions of stage B heart failure . Unfortunately , despite resources & large population of at risk and
burden of pre HF ,cardiology community was / is not paying enough attention on stage A & stage B heart failure
,rather after acute MI /revascularization ,we see inappropriate follow up and fragmented services.
Heart Failure
“ Pandemic in Pakistan “
Where we stand , Hero or Zero ?

Heart failure early Diagnosis , initiation of guideline directed medical therapy ( GDMT ) , target
dose titration and follow-up in Pakistan are fragmented , uncoordinated ,no structured HF
program / network & last not the least disappearing breed of HF physician scientists .
We are Hero in nuclear & missile technology but unfortunately Zero in advanced heart
failure therapy world .
Therefore development of specialized HF Program & networks ( Hub & Spoke ) is mandatory to warrant broad
access to guideline directed medical / device therapies for heart failure patients of Pakistan.
Our Heart failure care model has 6 ( six ) Pillars of care , 1) outpatient care 2) Inpatient care
3) Emergency care 4) community HF care 5) Home based HF care & 6) Virtual HF care . Last
pillar of care known as Virtual visit ,have emerged as an innovative and necessary alternative
to face to face visit , this will connect the Hub & spoke HF centers and will save money ,time
and thousands of kilometers of travel indeed .
Heart Failure
Where we stand , Hero or Zero?

Most of the cardiovascular societies recommend a three -level classification of structured
heart failure program & network . This comprises tertiary academic centers, specialized HF
regional units and specialized community HF clinics. (Level I to III Community heart failure
services to advanced heart failure center ) . Based on my 33 years HF experience & journey
from traditional HF clinic to JCI accredited CCPC Heart failure at kingdom of Saudi Arabia , here
is our initiative to become Hero from the Zero , in the form of building value based heart
failure manual , which is dedicated to sole of Shaheed ZA Bhutto .
The philosophy of the manual is to build heart failure program & network to improve
quality of life of HF patients and their families , improve survival ( death & disabilities ) and to
reduce recurrent and prolonged / premature hospitalizations .
( because 70% to 80% is spent on hospitalization ) .
Heart Failure

Its leftover homework of our physician scientist & health care providers for the last 75 years indeed.
Contemporary challenges are numerous , but there is a will there is a way ,today or tomorrow some body some
where has to start .
Currently heart failure is being treated by every physician ,any where from community to academic institution
,and is based on old system of payment ( FFP ) fee for service ,we need to switch from FFS to Value based
payment ( VBP ) . ( There is nothing free in the world , some body has to pay for the cost of heart
failure expenses ) . We need to change our strategy from treatment to prevention of HF .
Therefore We need to build & classify network of multidisciplinary novel HF program and
clinics ( Hub & Spoke ) .
Shaheed ZA Bhutto dedicated unique Heart Failure manual is in three parts on power point >
99 slides ,
Part 1) HF care model & specialized clinics network , Part 2) HF patient care &
Part 3) HF operational consideration . Its free on line , for any institution from community to
academic level ,who wish to build multidisciplinary HF program & clinic network .
Heart Failure

Soomro’s Classification of Heart Failure
Syndromes
.
“Benign or Malignant ?”
31.1.2022
De – Novo
HF Visited
ER .
1 ) 23.10.2021 Acute Inferior wall MI 3 VD CAD moderate LV systolic dysfunction, discussed in heart meeting, no intervention done . Stage B heart failure .
2 ) With in 3 months 31 . 1 . 2022 ist time developed De-Novo heart Failure ,visited ER but we managed him at home . ( Ist Pro BNP was 7794 )
3) On 11.3.2022 ist time admitted in CCU with acute heart failure ( pulm edema ) discharged next day 12.3.2022 ( Pro BNP reached to 35000 )
4) On 14.3. 22 readmitted again with confusion & UTI with hyponatremia inappropriately managed in local hospital in Karachi discharged on 16.3.22 .
5 ) On 29 .3.2022 readmitted confusion & discharged on 31.3.22 as DAMA . For home care . We managed hyponatremia ,recurrent infections & bed sores at home
6) After 11 months of HF home care ,readmitted on 20.2.23 with ADCHF precipitated by new NSTEMI & paroxysmal atrial Fibrillation managed medically and
discharged on 26.2.23 ,Since then managed at home ( HF Hospital at home cardiac monitor with ECG , Iv drugs O2 ) . No Visit to ER ,no HF hospitalization . On
31.7.2023 developed Upper respiratory viral infection , all Lab work stable Pro BNP raised from 2997 to 3960 , stabilized without antibiotic just given two extra
shots of 40 mg I/V Furosemide . From February 2023 to Feb 2024 remain compensated at home ,no visit to ER ,no readmission indeed.
Heart Failure Hospital at Home
HF journey from Stage B to transitional phase of stage D
Unique experience in Pakistan
1 2 3
4
31.3.2022 to
20.2.2023
Home care
Hospital at home
20.2.2023 Readmitted with
ADCHF precipitated by Afib
& new NSTEMI . Discharged
on 26.2.23
3 admissions in just 2
weeks
97 year old, our uncle ( our world )
No DM,HTN neither Smoker indeed
Had heart attack in October 2021
at Larkana ,CAG showed 3VD CAD ,
Developed ischemic Heart Failure
with severe LV systolic dysfunction
EF 25-30% . Severe MR &
pulmonary hypertension .
Persistently raised Pro BNP
,recurrent ADCHF & refractory
hyponatremia precipitated by
infections. We managed all at
home successfully. Alhamdulillah .
February 2023 to Feb 2024
Compensated phase .
My turning point for HF manual

I was born in Soomro family of Ratodero distt Larkana , graduated from Chandka medical college Larkana in 1985 . After internship in
general medicine and surgery at Civil Hospital karachi , I did three years hectic training at National institute of cardiovascular diseases
( NICVD ) Karachi Pakistan , and joined Royal Brompton National Heart & Lung Institute University of London (1989 to 1990 batch) one of the
students from all over world . After passing examination , got clinical attachment at Hillingdon hospital London ,had honor to work with Prof
philip poole Wilson and Dr GC Sutton , learned art of heart failure and clinical cardiology until April 1991. Returned back to Pakistan,
passed grade 18 Sindh Public service commission in flying colors ,secured first position in Sindh province and appointed senior registrar
cardiology at Dow medical and Civil hospital Karachi . Established first heart failure clinic in 1993 ,unique in country ,presented results
of 330 heart failure patients audit in Golden Jubilee and centenary 50/100 Dow medical College and Civil hospital Karachi in December 1996
( First largest local HF registry in Sindh) .
Came to Al Ahsa KSA joined King Fahad hospital ministry of health in January 2002, elevated to work as consultant & head of cardiology
division ( thanks to Dr Mehmoud al Bagshi) .Organized various heart failure symposiums in Al-Ahssa region. Offered to join Prince sultan
Cardiac center in 2007.Being PSCCH pioneer physician , I had honor to established three specialized clinics for , adult congenital heart disease
,Valve disease clinic and First heart failure clinic in region indeed. Completed my journey from heart failure clinic in Oct 2007 to
multidisciplinary heart failure programme in October 2017. During this period registered 550 patients with acute heart failure, unique in Al -
Ahssa health Eastern province Kingdom of Saudi Arabia . I had unique dual honor of being morbidity and mortality co-ordinator for 8 years
and CCPC Heart failure co-ordinator in 2017 ) . With in 6 months of dynamic team efforts Special thanks to Dr Khalil Kayam and his quality
team, our prestigious ( PSCCH) heart center accredited by JCI as first and only heart center in middle east as CCPC ( Clinical Care Programme
certification ) achiever in heart failure. ( All 3 Step PSCCH 10 years journey , Heart Failure Clinic, MDHF program & CCPC Heart Failure )
Authors Biography&
33 years Heart Failure journey
( 1990 – 2023 )

In August 2018 joined king Abdullah medical city holy Makkah ( KAMC ). Reactivated heart failure clinic on every
Tuesday evening from October 2018, with support of Dr Burai Adlan , Dr Najeeb Jaha, Dr Abdullah Essam Ghabashi and
support of adult cardiology/surgery department indeed .
We established network of multidisciplinary out patient HF services including cardio-oncology especially ,
chemotherapy induced cardiomyopathy ,had unique honor to provide intradepartmental heart failure consultation
service to patients admitted with acute heart failure, provided services of rapid access heart failure ( RAHFC ) and post
discharge heart failure clinic services ( PDHFC) to prevent ist admission and recurrent hospitalization especially to
vulnerable patients in vulnerable phase.
Registered around 993 HF patients including hajjis ( 2019) from various countries. First time started HF novel drug
( Sacubitril/Entresto) on 8th October 2018 until May 2021, 330 sacubitril patients registered and followed them closely .
52.1 % of them titrated to target dose of 200 mg ( highest in Makkah region).I wish I could have worked to have CCPC
,KAMC Makkah region, but I stand retire and decided to join family on 3rd July 2022 .
Last not the least , Iam grateful to all who gave me tough time and who helped me all along.
Jazak Allah khairan Ya Akhwan.
Authors Biography &
33 years Heart Failure Journey
( 1990 – 2023 )

( Dr GC Sutton , my Heart Failure mentor and his team)
Hillingdon Hospital London (1990 to 1991) My heart
failure journey started from here

Heart Failure Journey at Civil hospital and Dow medical
College Karachi ( Established First heart Failure Clinic &
HF registry at CHK 1995 to 1997 )

I was appointed as Clinical care Heart Failure program ( CCPC) coordinator
on 2nd April 2017. CCPC heart failure was accredited by JCI on 18th October
2017 ( with JCI CCPC HF Surveyor Brenda K. Shelton ) just in 6 months.
Dr Soomro’s Heart failure Journey at PSCCH
Established first Heart failure Clinic at Prince Sultan Cardiac Center Al - Ahassa region in 2007 followed by multidisciplinary heart
failure program ( MDHFP ) which was accredited by JCI as Clinical care Heart Failure Programme ( CCPC ) First in middle East in
October 2017.
It was long journey , started while working at King Fahad hospital Hofuf, In April 2017 was appointed as CCPC heart failure
co-ordinator . Being PSCCH pioneer physician, I alone screened all previous cardiac patients from King Fahad hospital , and registered them on
specialized clinics ,like adult congenital heart ,Valve disease and heart failure cases indeed. While working at PSCCH , I registered around 550
acute heart failure patients admitted to PSCCH during 2011 to 2017.

Dr Asadullah Soomro
Morbidity & Mortality Co-Ordinator PSCCH Al-Ahsa KSA
October 2009 to October 2017
I was assigned a job of morbidity & mortality coordinator on
6th september 2009 . Ist morbidity & mortality round was held
on Monday afternoon 30th Shawal 1430 (19.10. 2009).
Ist case was 87 year male who was admitted on 15th shawal 1430 at 1.25am
Sunday on CCU bed 6 .He was admitted through ER with missed MI
( LBBB on EKG) No DM HTN only smoker. Echo showed akinetic anterior
wall severe LV systolic dysfunction EF 15-20%, not thrombolysed.
Complicated by cardiogenic shock. Intubated & ventilated on inotropes and
expired on same day at 7.50 am ( with in 9-10 hours of admission ) .
After 8 years journey , Last case I audited ,76 year male ,DM, PAD,
presented with acute anterior wall STEMI with RBBB ,complicated by
cardiogenic shock at presentation.
Admitted on Tuesday 24th October 2017 at 1.51pm, shifted to cath lab .
CAG showed multi vessel CAD. RCA was CTO ,LAD total thrombotic
occlusion proximally, intubated ventilated, on inotropic support .During PCI
to culprit LAD further complicated by ventricular fibrillation, resuscitation
done but failed and expired at 3.51pm ( With in 2 hours of admission) .

Heart Failure Journey From 2018 to 2021
King Abdullah Medical City ( KAMC ) Holy Makkah .
Heart Failure Program co-Ordinator , member of GWTG ( AHA ) .

MHFR ( Makkah Heart Failure Registry)
Saudi Heart Association Conference 7th October 2021
Total Patients 993 Average Age 56.9 + _ 13.2 years ( Men 752 ( 75.7% ) Women 241( 24%
Patients Demography and clinical characteristics
Registry groups &
No of Patients
Location of registry
Type of Registry
Average Age
Men/ Women %
Ischemic Etiology
Valvular Etiology
On Target Dose
Of Sacubitril
Average LVEF %
HF in Saudis
Deaths = 90
Group I = 330 ( 33.2% ) Group II = 586 ( 59% ) Group III = 77 ( 7.7% )
Acute & chronic HF KAMC Cardiac
Center ( October 2018 to june 21)
Acute & Chronic HF KAMC Cardiac
Center ( October 2018 to June 21 )
Acute HF KAMC Cardiac Center
30 Days ,August Hajj 2019
Sacubitril Registry EF < 40% Non Sacubitril Registry
Both systolic and Perserved EF
Non Sacubitril Registry
Both Systolic & Perserved EF
53.9 +_ 12.3 Years 57.7 + _ 13.5 Years 63.8 + _ 10.8 Years
Men 278 ( 83.5 % ) Women 52 ( 15.7% ) Men 424 (72.2 % ) Women 162 ( 27.6%) Men 50( 64.9 % ) Women 27 ( 35% )
128/330 ( 38.7% ) 250/586 ( 42.6% ) 50/77 ( 64.9% )
15/202 non ischemic ( 7.4% ) 95/ 314 ( Non ischemic ) 30.2% 15/27 ( Non ischemic ) 55.5%
172/ 330 ( 52.1% ) Not Prescribed Not Prescribed
23.2 + _ 7.4% 31.7 + _ 10.8 % 33.8 + _ 0.4%
290/330 ( 87.8% ) 524/685 ( 89.4% ) 2/77 ( 2.5 % )
23 /330 ( 6.9% ) M = 18, F = 5 52/586 ( 8.8 % ) M = 42,F =10 15/77 ( 19.4% ) M = 11 , F = 4
MHFR ( Makkah Heart Failure Registry)
Saudi Heart Association Conference 7th October 2021
Total Patients 993 Average Age 56.9 + _ 13.2 years ( Men 752 ( 75.7% ) Women 241 ( 24% )
Patients Demography and clinical characteristics

Building First multidisciplinary
Heart Failure
Programme ( MDHFP/CCPC ) & specialized clinics network ( Hub & Spoke )
, sindh Pakistan.
Part I

Heart Failure Facts
>64
million
>64 million patients worldwide are living with Heart Failure
( 1-2% of the global population ).
By 2025 30% of the global population will have heart failure.
Frequent
9 of
10
Progressive
Mostly its incurable syndrome, can be reversible
Patients have symptoms despite treatment .
HF is associated with reduced quality of life .
Mortality
Exceeds Most
Cancers
Deadly & Complex syndromes
77%
5 year mortality of HF exceeds prostatic
cancer. >10% die during De-Novo
hospitalization, decline in survival but at
the cost of recurrent hospitalization
Economic burden of HF is 108
Million dollars worldwide
( 2017) 92,990 high income
and 15,130 in low income
countries.
About 387 million dollars
/year in KSA
Costly ,especially admission and
readmissions .
Heart Failure Overview

Shocking Cost on Admission &
Readmission HF Syndromes
Out of 3.75 million HF patients in gulf region, an estimated 1.5 million patients are suffering from
heart failure in three countries.( UAE, KSA and Egypt ) . Highest number, (998 900) in Egypt only
Annual Per patient cost was highest in UAE ( USD ,14121 )
Followed by KSA ( USD 8404 ) Lowest ,yet ( USD 1105 ) in Egypt.
Total Estimated Cost for the MENA region is
USD 4.88 billion.
Highest in KSA
USD 2.63 billion
UAE
USD 1.25
Billion
Egypt
USD 994.96
Million
Major Cost associated on Inpatient care , on admission , readmission , & invasive procedures
Estimated Cost of 4 key HF medications per year = 3622 SR, ( Cost of sacubitril per year per patient 7665 SR )
9162 SR
4 HF Drugs
Per /Pt
Per/Yr
ARNI, MRA
B Blockers
& Diuretics
Shocking Cost on ist admission &
Readmission HF Syndromes

A
&
B
56%
C
D
HF
Stage
A-D
Color
Code

Heart Failure remains a leading cause of death &
disabilities all over the world and in Sindh/Pakistan
indeed.
Through this document , Sindh heart failure service aims
to provide a contemporary ,practical guide to creating
and sustaining a network of multidisciplinary heart failure
clinics / Program.

1) Establishment of the network of multidisciplinary
Novel Heart failure Clinics in Sindh Pakistan.( like CHFC
, RAHFC , PDHFC , Advanced HF , Nurse led HF, Virtual HF , regular HF clinic
SDHFC ( same day for OPD based I/V diuretic & inotropes ) , Cardio -
oncology , cardio - andrology & Cardio - obstetric heart failure Clinic .
2) Implementation and monitoring of updated
guidelines on heart failure diagnosis and management.
Aims of the ZA Bhutto
Multidisciplinary value based Heart Failure Programme & Network

3) To familiarize and encourage cardiology
community to apply evidence based therapies and
discoveries to prevent or delay of development of pre-HF
to overt heart failure to advanced HF , and prevention of
deaths before onset of symptoms .
Multidisciplinary value based Heart Failure Programme & Network

4) To promote heart failure prevention by public
education ,on healthy life style, HF symptom awareness
and self-care to prevent recurrent decompensation and
Heart Failure hospitalization.
5) Introduction of heart failure rehabilitation and create
a highly supportive habitat for research in heart failure
especially amongst disappearing breed of physician scientists.
MultidisciplinaryValue based Heart Failure Programme & Network

Healthy Heart for
Everyone everywhere in
Pakistan.
Vision
Z A Bhutto Multidisciplinary Value based
Heart Failure Program& Network

Our mission is not only to improve
the quality of life and longevity of
heart failure patients, but to keep
them out of the hospital indeed.
Mission
Z A Bhutto Multidisciplinary Value based
Heart Failure Program& Network

GWTMG
( Get with the Makkah Guidelines )
KAMC / AHA
What is value-Based Care?
It has emerged as an alternative & potential
Replacement for fee -for - service reimbursement Based on
quality rather than quantity.
What it means for providers ?
Type of reimbursement for quality of care provided
and reward, providers for both efficiency and
effectiveness .( Better care at reduced cost )
What is value-Based ( VBC ) Care?
It has emerged as an alternative & potential
Replacement for fee -for - service reimbursement , Based
on quality rather than quantity.
What it means for providers ?
Type of reimbursement for quality of care provided and
reward providers for both efficiency and effectiveness .
( Better care at reduced cost )
Advancing Value Based Models for Heart Failure syndromes

GWTMG
1) First Fee for service ( FFS ) pays for illness rather than wellness .Few or no
resources for prevention of heart failure . ( like diet and life style changes )
2) Second ,many of these preventive measures could and should be done by non
specialist ,community physicians or even trained nurses but there is
no reimbursement of their service .
3) Third Fee for service tends to separate primary and specialty care , which
handicap care coordination needed for chronic management of stage A & B HF.
4) Fourth Fee for service encourages invasive and intensive treatment like
ICD,CRTD ,LVAD and Heart transplant but none for palliative care.
KAMC / AHA
Fee for illness ( treatment ) not for wellness ( prevention ) of Heart Failure
“ Payment landscape is changing “
Fee for illness ( treatment ) not for wellness ( prevention ) of
Heart Failure
“ Payment landscape is changing from FFS
to VBP “
Target Heart Failure Prevent Heart Failure
Established chronic compensated heart
failure Stage C
To prevent progression to acute
decompensation ( ADCHF ) and
recurrent hospitalizations .
Prevention of progression of stage D
advanced heart failure
Target high risk stage B Pre - heart
failure ( asymptomatic )
Patients to prevent development of
symptomatic stage C
Acute De – novo heart failure .
“ Prevent Pre HF from turning into HF “
Challenges in implementing a value based model ,bit difficult but not impossible .
We need to build organizational competencies and infrastructure for multidisciplinary
HF Program ( MDHFP ) & Network . It require adequate experienced & skilled workforce .
AHA ( GWTG ) Project My ( GWTG ) Project
GDMT Shift from inpatient to ambulatory outpatient Setting

GWTMG
KAMC / AHA
Goal
Advancing Value-Based Model for Heart Failure Syndromes
Despite tremendous progress in improving heart failure care ,yet quality of HF care varies
greatly across the Makkah healthcare cluster .
One major challenge underpinning heterogeneous issues is the current payment system,
which is largely based on “ fee for service FFS” reimbursement.
This Episode based payment ( FFS ) model for HF hospitalization,/ Cardiac intervention &
device implantation, without focus on post discharge uncoordinated ,fragmented and low
quality transitional Care , while landscape is changing to value based model of care, is thought
provoking for heart failure multi stakeholders.
High risk stage B HF ( Old MI / LV dysfunction ) Progression to Symptomatic Stage C and stage D
1) Despite tremendous progress in improving heart failure care ,yet quality of HF care varies
greatly across the Sindh / Pakistan healthcare cluster .
One major challenge underpinning heterogeneous issues is the current payment system,
which is largely based on “ fee for service FFS” reimbursement.
This Episode based payment ( FFS ) model for HF hospitalization,/ Cardiac intervention &
device implantation, without focus on post discharge care is uncoordinated ,fragmented and
low quality transitional Care .
while landscape is changing to value based model of care, is thought provoking for heart failure
multi stakeholders.
Goals of Value Based
Care

GWTMG
KAMC / AHA
Goal
Advancing Value-Based Model for Heart Failure Syndromes
” Goal is straightforward but ambitious:
Replace the Makkah heart failure populations reliance on
fragmented, low quality, fee-for-service care
with comprehensive ,coordinated care using payment models that
hold organizations ( KAMC and Makkah healthcare cluster )
accountable for cost control and quality gains.”
High risk stage B HF ( Old MI / LV dysfunction ) Progression to Symptomatic Stage C and stage D
2) Goal is straightforward but ambitious:
Replace the Sindh/Pakistan heart failure populations reliance on
fragmented, low quality, fee-for-service care
with comprehensive ,coordinated care using payment models
that hold organizations ( Sindh healthcare cluster )
accountable for cost control and quality gains.
Goals of Value Based
Care

GWTMG
KAMC / AHA
Fee for illness ( treatment ) not for wellness ( prevention ) of Heart Failure
“ Payment landscape is changing “
Fee for illness ( treatment ) not for wellness ( prevention ) of
Heart Failure
“Goals of Value Based
HF Care”
3) There is a dire need for a long-term value based model to
improve care and reduce costs for patients with heart failure .
4) Current HF payment models ( FFS ) are largely based on short term
episodes, focus on acute events or procedure ( HF hospitalization/
Cardiac intervention ) .
5) There is a big gap for patients with HF, who need long-term care after
discharge from hospital / HF procedure , to improve function, back to work ,
prevention of iatrogenic complications, Heart Failure admission & Re-
admission syndromes .

The guide discusses the steps to consider before
building MDHFP, which is broadly categorized as ,
1 ) patient care consideration for delivering GDMT and medical
responsibilities of MDHFP / clinic for patient care .
2 ) Operational considerations including structure and efficiency of
performing MDHFP / clinics .
This document was developed to empower dedicated physicians
wish to build and sustain state of art multidisciplinary heart
failure programme & Network.

Steps to build
ZA Bhutto Multidisciplinary Heart Failure
Program in Sindh /Pakistan
1) Establish the goals of ( MDHFP ) multidisciplinary heart failure programme.
2) Develop referral criteria & publicize criteria within community.
3) Determine specific HF population ( Stage A to D ),and which patient to be seen
where ( level I to IV ).
4) Assess physical location for the clinic, and type of HF patient ( RAHFC )
5) Appoint MDHFP director / Governor and HF clinic leaders/Co-ordinators.
6) Determine/appoint MDHFP staffing model, HF physician/dedicated medical
specialist interested in HF, Clinical/HF nurse. In addition , allied health
professionals ( Pharmacist, educationist/nurse, nutritionist, exercise
physiologist/physical therapist, psychologist/social worker, Financial/Admin
Coordinator.

Steps to build
7) Create clinic appointment structure, ( new patient, follow up, urgent ).
8) Develop clinical practice pathways & protocols
( Inpatient/outpatient)
9) Develop partnership with other relevant subspecialists , Nephrology
10) Develop partnership with frequently used clinical services ( EKG,
Echo, CMRI, CPET, Cath lab, cardiac rehabilitation ,palliative care.)
11) Develop a technology and Virtual visit infrastructure .
12) Establish mechanism for patient follow-up .

Steps to build
13) Create hospital coverage plan.
14)Determine mechanism for quality improvement
15) Develop Business plan for HF clinic ( Value Based
Model of HF )
16) Develop a technology and virtual visit infrastructure
17) Build research network ( Optional)
18) Obtain appropriate accreditation
( JCI, AHA,ACC ) ( Optional )

Aziz Medicare
Soomro’s Classification of Heart Failure Network
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 but without cath Lab.
Model 4
All + Advanced Heart Failure service
With Intervention, LVAD and
Cardiac transplant Capability.
Grade /
Level
I
To
IV
Model 3
Heart Failure service Model 2 +
Cath lab & revascularization
capability
Soomro’s
Classification of Inter-hospital Heart Failure network

Soomro’s
Parsimonious Model ( Six Pillars ) of
ZA Bhutto Multidisciplinary State of Art
Heart Failure Program Sindh / Pakistan .
Home Based
Heart Failure
Service
Virtual
Heart Failure
Service
Outpatient
Heart Failure
Service
Emergency
Heart Failure
Service
Community
Heart Failure
Service
Inpatient
Heart Failure
Service
4
2
3
1
5
6

This Clinic is for new onset ( De-Novo ) HF patients with mild to moderate symptoms , or suspected heart failure
patients & those who left DAMA from ER, its walk in clinic . Target is all basic HF work up on same day.
This clinic is for those patients who were admitted & discharge from the ward ,CCU,ICU with diagnosis of ADCHF ( Acute
decompensation of chronic HF ) & New onset Heart Failure. ( Telephonic call on 3rd day and clinic appointment With in 10-15 days post discharge)
This clinic is for tiny group of complex ambulatory advanced heart failure stage D , not suitable for advanced therapies ( LVAD or OHT )
or waiting for advanced therapies &for those with Post LVAD /Post heart transplant.
This community based HF clinic for care of stage A and stage B Heart failure . With mild to moderate new onset HF patients for early
referral to RAHFC & For post discharge early follow up / HF education and self care Zone awareness at community level.
This clinic is for Compensated HF patients who are living away from Karachi can follow on this clinic ,if need can be
reviewed on regular HF clinic. ( To save thousands of Km travel, petrol, time , leave and cost saving indeed )
This clinic is for compensated HF patients under follow up /and for those who require Guide line directed medical
therapy (GDMT ) dose titration until fulfill dispose criteria . Special clinic for Sexual problems in cardiac patients .
This clinic is for those patients who are in need of regular I/V diuretics & inotropes on OPD basis to avoid frequent
ER visits and readmissions. This clinic can be utilized for ER patients who refuse admission/DAMA as an alternative.
Its multidisciplinary clinic for HF education, clinical pharmacist medication ,Dietary education , HF rehabilitation
,social problems , anti smoking and drug counseling issues & miscellaneous problems.
This clinic is exclusively for Cardio-oncological problems with heart failure evaluation & follow up.( post Chemo & radiotherapy )
Cardio-obstetric HF clinic is for heart diseases in pregnancy and Peri-partum cardiomyopathy patients .
Rapid Access HF Clinic
Post Discharge HF
Clinic
Advanced HF Clinic
Community HF Clinic
Virtual HF Clinic
Regular HF Clinic
Cardio-andrology clinic
Same day HF Clinic
Nurse Led HF Clinic
Cardio-oncology &
Cardio-Obstetric Clinic
Soomro’s
Network of ( 11 ) Novel Heart Failure Clinics ,
Sindh/Pakistan .
GDMT Shift from inpatient to ambulatory outpatient Setting

Multiple Stakeholders of Heart Failure
Programme & Healthcare 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
8) Finance & Health
Ministry representatives
Education
9) Professional associations
& Donor & social agencies
Education
Multiple Heart Failure Stakeholders
7 star HF education ,education & education

Heart Failure Self Care
“When to contact physician or visit ER ”
Every heart failure patient,
family ,paramedical personnel
and community physicians
indeed should be aware of
heart failure Zones .
Ideally every patient
,every day should be green
“ Ever Green”
Score Zero
Yellow
Zone
Get alert ,
Warning Signs
( Number 1 to 5)
Adjust your fluid,
salt, diuretic or call
your physician
Red
Zone
Emergency
( Call ambulance
To visit ER.
If number
6 to 10 )
Heart failure Zones
Heart Failure awareness & Self Care
Green Zone
Ideally every patient
,every day should be
“ Ever Green”
Score Zero
Stay at home
Yellow Zone
Get alert ,
Warning Signs
( Number 1 to 5)
Adjust your fluid, salt,
diuretic or call your
physician
Red Zone
Emergency
( Call ambulance
To visit ER.
If number 6 to 10 )
Every heart failure patient, family , paramedical personnel and community physicians indeed should be aware of
heart failure Zones .

1) When you gain ( from dry weight ) more than 2 pounds /one
kilogram weight in a day or 5 lb/2kg in a week .
2) Worsening of dry hacking cough in lying down get better in sitting
down with pink foamy spit or sputum with or without fever.
3) Increase in swealing of your feet, ankles , legs and scrotum .
4) Recurrent abdominal especially right hypochondrial pain with
tenderness with or without abdominal fullness and jaundice .
5) Extreme tiredness or weakness FC 111 ,1V , and If you think your
symptoms are related with medications .
Heart Failure Awareness & Self Care

6) Sudden Shortness of breath FC 111/1V or orthopnea or PND
( shortness of breath in lying down / need more pillows at night or wake up
from sleep at mid night ).
7) Sudden or recurrent dizziness with syncope / fall down sustain injury.
8) Sudden or worsening of retrosternal chest pain /pressure
( Typical ischemic Pain) .
9) If your pulse or heart beat gets very slow or very fast with low blood
pressure with or without dizziness/ syncope.
10) If you think your symptoms are related to new procedure (
PCI/cardiac surgery ) or device implantation (inappropriate shocks
, fever , hypotension ,chest pain & breathlessness.
Heart Failure Awareness & Self Care

Building First multidisciplinary Heart Failure Clinic/
Programme ( MDHFP/CCPC )
, sindh Pakistan.
“ Patient Care Consideration “
Part II
First Multidisciplinary value based Heart Failure

Improving Heart Failure
Services for people in Larkana
Building Multidisciplinary
Heart Failure Programme
( MDHFP )
and network
in Sindh Pakistan.
Part II
INTRODUCTION
Heart Failure is a complex clinical syndrome and leading cause of mortality and
morbidity Globally and in Sindh/Pakistan indeed.
The cost of caring for HF patients is enormous , especially ( 77-80% ) on
hospitalization.
Overall prevalence of HF has declined but at the cost of increased rate of
ist admission and re-admissions, despite our patients are 10-15 years younger
than western counterpart.
HF services are fragmented ,there are imminent communication gaps amongst
stakeholders, with the result, there is suboptimal transition of care and gaps in
implementation of GDMT.

Improving Heart Failure
Services for people in Larkana
Building Multidisciplinary
( MDHFP )
and network
in Sindh Pakistan.
Part II
Why Heart Failure is on rise?
HF population is on rise and will continue to increase in coming decades, due to
increased rates of metabolic syndromes, diabetes , improvements in
treatment of myocardial ischemia & infarction , cancer , cardiac
intervention & last not the least increased trend of offending drugs
( Captagon, Alcohol & hashesh) in young generation.
Patients are also living longer due to the spectacular gains from heart-failure
medications. This means that we will continue to see much more heart failure
in the community in the coming years.
Advances in heart failure therapies, including medications and devices,
promise that this will continue to be a dynamic and changing chronic disease.

LHFS
Need for MDHF Programme
For these reasons, Sindh heart failure aims for
development and refinement of high
performing Multi Disciplinary HF Program.
( MDHFP ) & network of HF clinics in Sindh
healthcare cluster, to provide guideline-
directed, technology-enabled, high-quality
comprehensive care at low cost ( Value based ).
Need for MDHF Programme

LHFS
HF Care Considerations
The specific consideration put forth are broadly
categorized in two parts.
1)Patient Care Consideration for delivering
Guideline directed & patient-centered care.
2)Operational consideration, which focus on
optimizing the structure & efficiency of the
programme.
Building Heart Failure Programme

LHFS
Steps to build MDHFP
Any institution seeking to launch a HF programme
,should be aware about steps before beginning that
endeavor.
Steps to build Multidisciplinary
HF Program
Patient
Care Consideration

LHFS
HF Patient Care Considerations
1) New Patient Evaluation
2) Follow-up visits after initial assessment.
3) Medical therapy evaluation
4) Device Therapy Evaluation
5) Functional status assessment
6) Quality of Life Assessment
7) Administration of I/V diuretics ( Outpatient infusion center )
8) Outpatient management of inotrope therapy
9) Palliative and End-of-life Care
ZA Bhutto HF Program
Patient Care Consideration

LHFS
Goals of MDHFP
1) Identify Patients with HF .
2) Evaluate etiology of HF and
establish an appropriate
diagnosis
3) Develop clinical care pathway .
4) Initiate & titrate guideline
directed medical therapy ( GDMT)
5) Provide education & self care
material to HF patients .
6) Refer patient with confirmed or
suspected diagnosis to ( RAHFC ) to grade II
HF clinic or advanced HF center if fullfil
criteria ( Ref to “ I NEED HELP
“ )
7) Develop mechanism for continuous
quality improvement.
1) Same as grade I HF clinic .
2) Use structured medications up-
titration to reach GDMT doses of
medications.
3) Evaluate and consider for device
therapy ( CRT, ICD ) .
4) Provide education & self care
material to HF patients .
5) Refer patient with confirmed
advanced HF to Grade III center if
fulfill criteria ( Ref to
“ I NEED HELP “ )
6) Discuss prognosis with patient .
7) Develop mechanism for
continuous quality improvement
1) Same as in Grade II HF clinic
Evaluate patient for home
inotropic therapy ,mechanical
circulatory support ( MCS ) ,and
orthotopic heart transplant (OHT )
Provide ongoing care
as mentioned above.
2) Monitor quality improvement
For Academic institutions,
consider scholarships for
fellows and nurses in
heart failure
( National/International)
Grade I Community HF Clinic Grade 11 General Cardiology /HF clinic Grade 111 Advanced HF Clinic
Goals of building ZA Bhutto Multidisciplinary Heart
Failure Program ( MDHFP )

MHFS
New Patient ( De-novo HF ) Evaluation
Main Goal of HF Service ( public or private model I to III ) for any new HF patient is to
confirm diagnosis of HF and its etiology.
Specific consideration should be given to several mimics of HF including primary pericardial
diseases, chronic lung , renal and liver diseases .
Diagnosis of HF is mainly based on detail history and thorough physical / CV
examination ( sign & symptoms ) followed by blood work, EKG, X-ray and
echocardiogram.
Most of the patients with mild to moderate symptoms usually go to community family
physicians and severe symptoms directly go to emergency department of nearby hospital and
are usually admitted , or after symptom improvement go DAMA.
If no appropriate action or alternative available ( like rapid access HF clinic RAHFC /SDHFC
),then they suffer a lot until diagnosis is established , they are either complicated to severe
acute HF/Cardiogenic shock or die suddenly.
New Heart failure ( De-Novo )
Patient Evaluation

LHFS
NEW ONSET HEART FAILURE JOURNEY
RAHFC
( RAPID ACCESS HEART FAILURE CLINIC )
Patients with severe symptoms
Before diagnosis of
Heart Failure go to emergency.
Patients with Mild to
moderate symptoms Before diagnosis of
Heart Failure usually go to family physician
POST DISCHARGE
With in 7-14 days
Out Patient Multidisciplinary
Clinic
Phased based Inpatient Care
Heart Failure Clinic Community HF Clinic
Long Term Heart Failure Management
NO
Heart Failure
Disposed
Or
Follow up as
Stage A& B
Heart failure
Cath
Lab
OR
CCU
Ward
Treated
& go DAMA
Admission
New Onset ( De-Novo ) Heart Failure Journey

LHFS
Follow Up Visits.
After the initial assessment ,a focus should be placed on initiation of
GDMT and escalation to the target or maximally tolerated doses with
in 3- 6 months after confirmation of a diagnosis.
It should be achieved in stepwise fashion with clinical and lab
monitoring.
Patients with HF and LV systolic dysfunction ,who do not have recovery
Of EF to > 35% with target or maximally tolerated GDMT should also be
assessed for for ICD or CRT.
Emphasize on HF education and self care zones, for self-titration of
diuretics according to home monitoring weight and worsening of
symptoms .
Follow up Visits

LHFS
Medical Therapy Evaluation
Guideline Directed Medical Therapy ( GDMT ) prescription, dose titration
and adherence ,is the cornerstone treatment for heart failure , and is
primary responsibility of the heart failure clinic.
In heart failure with LV systolic dysfunction, evidence from large clinical
trials and clinical guidelines strongly support use of “triple therapy” at
target doses as tolerated , which includes ACEI/ARB/ARNI ( class 1
recommendation to switch to ARNI ) , Beta-blockers and mineralocorticoid
receptor antagonist ( MRA) .
They all proven to improve.
1) Survival 2) Reduce hospitalization
3) Improve Quality of life

LHFS
Despite strong guideline recommendations and evidence there remain major gaps in use , dosing
and target dose titration ( as tolerated ) .These gaps have not meaningfully improved in the
past decade ,but vary widely across practices.
Across all components of triple therapy ,up to 50% - 80% of patients eligible ,remain on stable
subtarget doses or no dose indefinitely.
Each patient encounter should be recognized as an opportunity to initiate and up-titrate
GDMT, up to target dose as tolerated.
Stable symptoms should not be primary reason for not escalating GDMT ( Risk of mortality
/SCD in HFrEF )
For patients not receiving GDMT or receiving subtarget doses , justification and clear
documentation should be present in the medical record . If prior symptoms or adverse events
on up-titration , should also be documented.

LHFS
Device Therapy Evaluation
The role of implantable cardiac devices for heart failure
is rapidly evolving.
ICD & CRT ( Cardiac resynchronization therapy ) remain
with strong guideline recommendations, but field has
expanded recently for CardioMEMS device as an
implantable hemodynamic monitor, and transcatheter
mitral valve repair ( Mitra clip )for significant mitral
regurgitation .
Device therapy Evaluation

LHFS
Device Therapy Evaluation
Before Device implant as per clinical guidelines , Do not hurry especially in
de-novo heart failure with slow pace of GDMT initiation and dose titration.
Take care of at-least few things
1) Thoroughly look for reversible causes of LV systolic dysfunction
2) 3-6 months should be allowed to assess LV recovery & MR regression especially in
idiopathic non dilated non ischemic cardiomyopathy with optimal GDMT.
3) Life expectancy and functional class should be reviewed in context of clinical
guideline recommendation ( Treat Patients not just MR /LVEF)
4) Open discussion amongst stakeholders regarding benefits of device therapy at the
cost of long term risk ( like Device infection ) & alternative. Educate them about
periodic device interrogation ,alerts ,inappropriate shocks & monitoring
Device therapy Evaluation

LHFS
Functional Status Assessment
The functional status evaluation is an important component of all new
onset and follow-up HF patients visit.
Three methods have been subject to extensive research and clinical use.
1) New York heart Association ( NYHA 1-IV ) functional class .This is very old method
,and has been used as one of the eligibility criteria in HF trials. Worsening FC
correlates with a stepwise increase in the risk of death and hospitalization.
2) 6 – minute walk test ( 6MWT ) The 6MWT is a simple and objective measure of
functional capacity that correlates moderately with peak oxygen uptake .A
threshold 6MWT of 300 m has been traditional benchmark for increased mortality
risk . Ideally this test should be performed in HF clinic visit ( as feasible) in efforts to
detect subclinical worsening of functional status. It has limitations in advanced age
, obesity , artheritis & COPD patients.

LHFS
3)Cardio-pulmonary exercise test ( CPET ) Measured peak oxygen
uptake ( Oxygen consumption) .It is most objective means to evaluate
exercise capacity in patients with HF. It can be performed via treadmill
or bicycle protocol . CPET may be considered to inform patient
candidacy and necessity for advanced HF therapies ,( like heart
transplant or LVAD implantation ) and to differentiate cardiac versus
non-cardiac causes of dyspnea and fatigue . This is specialized
equipment and need trained personnel to conduct and interpret a
CPET and is not available at all centers.( not in holy Makkah ) .
Last not the least Novel wearable accelerometers to measure daily
activity level.

LHFS
Quality of Life Assessment
1) Monitoring and optimizing heath related quality of life and
patient reported outcomes ( PRO) is an important goal of the
HF clinic.
2) To ensure a patient centered experience ,it is important to
accurately and validly capture patient s experience with HF.
3) PRO ( patient reported outcomes) is a instrument provide a
“standardized history “ in that they directly ask patients
relevant questions about their health the same way each
and every time.

LHFS
4) There are multiple valid , reliable , and sensitive PRO
instrument available ,the most well –studied is the Kansas City
Cardiomyopathy Questionnaire ( KCCQ -12 ) and Minnesota
Living with HF questionnaire. Last not the least is Euro QOL -5
dimension is generic instrument.
5) It is recommended that all HF clinics strive to incorporate a
standardized and routine assessment of patient quality of life
with a validated PRO instrument .PRO are strongly associated
with subsequent risk of death and hospitalization.

LHFS
(SDAHFC )
Same day access (out patient based ) Heart Failure Clinic
Outpatient based I/V Diuretic therapy
1) Approximately 90% of patients hospitalized for HF may receive I/V diuretic therapy
and many receive no other IV therapies before discharge.
2) Recognizing that diuresis is the primary intervention during most hospitalizations for HF
and that some patients quickly improve with in few hours.
3) Therefore why not to offer this facility at outpatient level in selective patients ,which is
less costly then recurrent visits to ER and hospitalization.
4) It just require dedicated space to administer I/V diuretic, observe them ,monitor renal
function and electrolytes and can go home.
5) Same day access HF Clinic visit may be either scheduled in advance or walk-in visit
for worsening of symptoms. Assigned staff has to be available .
Same Day Access ( Out patient based )
Heart Failure Clinic

LHFS
(SDAHFC )
Same day access (out patient based ) Heart Failure Clinic
Outpatient based inotropic therapy
1) There are two scenarios in advanced HF where
( Milrinone , dobutamine , dopamine ) is common treatment strategy . One advanced HF
patient bridged to heart transplant or durable LVAD decision 2nd patients not
eligible or declined for advanced therapies and is on palliative care at home or
hospice .These patients may benefit from continuous infusion. Its difficult but not
impossible alternative to ER and recurrent hospitalization.
2) This area can be utilized for dose monitoring ,increase or decrease , Vitals, blood
sampling and to assess complication related to CVP line infection or ICD shocks .
3) These patients have bad prognosis, so advance planning by patient family and caregivers
is critical.
Same Day Access ( Out patient based )
Heart Failure Clinic

LHFS
Palliative & End-of-Life Care
Despite the recommendations, palliative care for heart failure remains underused and is
almost exclusively used in the inpatient setting.
30% Patients with heart disease especially heart failure are bedbound ,yet
palliative care consultations occur in the last month of life. Patients with HF are
more likely to die in a medical facility and less likely to die at home as compared
to cancer.
Recognizing common symptoms of heart failure ( Like breathlessness & edema ) are relatively
easy ,but attention should be paid to less obvious HF symptoms ( Like pain, anorexia &
depression ) and palliative care intervention improve quality of life in end stage HF
syndromes.
Dedicated palliative care specialist should be consulted early and advanced directives may
be documented in electronic medical record. Discussion should involve not only patient but
with caregivers and payers indeed.
Disease prognosis ,goals ,transition to hospice care ,power of attorney and DNR may also be
discussed and documented in EMR.
Palliative & End of Life Care

Part III
Patients Operational
Consideration

KAMC Heart Failure
Organizational Structure
One Heart Failure
Governor
2 to 3 Heart failure
cardiologists
Heart Failure governors responsibility is to supervise multidisciplinary HF program, he should be preferably heart failure cardiologist / dedicated cardiologist interested in heart failure.
Since HF program has four components , one HF cardiologist will take care of inpatient heart failure unit and intra / extra departmental consultations and emergency heart
failure services up to 4 pm. 2nd HF cardiologist will look after multidisciplinary specialized heart failure clinics and Virtual community heart failure services.
3rd HF cardiologist will cover deficiencies and to cover services during vacations.
Heart failure nurse coordinators will rotate to cover nurse lead HF out patient clinics, inpatient heart failure unit services, emergency department HF services and assist in virtual
community heart failure services. HF clinical pharmacist ,dieticians, educationist, heart failure cardiac rehabilitation and exercise physiologist ,last not the least social worker and councillor
3 to 6
Heart Failure
Nurse
Coordinators
Dieticians
Clinical
Pharmacists
Cardiac
Rehabilitation
/ Exercise
physiologist
Heart Failure
Educationist
Social
workers/
Councilor
Heart Failure
Organizational Structure

KAMC
HEART FAILURE
CARDIOLOGIST
Family Physician Emergency
Physician
Clinical cardiologist
Non Invasive
Interventional
Cardiologist
Cardiac Surgeon Electrophysiologist
Anesthesiologist Imaging specialist
Cardiac
Radiologist
Cardiac
Pathologist
CHD HF &Cardiac
Morphologist
Diabetologist Nephrologist Pulmonologist
Cardiac Rehabilitation
Cardio-oncologist
Neurologist Dentist
Heart Failure Nurse Heart Failure Educationist Clinical pharmacist Exercise physiologist Dietecian
Cardio-obstetrician/neonatologist
Multidisciplinary Team

LHFS
HF patients operational considerations
Operational consideration, Focus on optimizing the structure &
efficiency of the programme.
1) Determine Specific Patient Population.
2) Determine Triggers for expected Referral.
3) Assess physical location of clinic
4) Appoint Appropriate clinic Leadership
5) Determine clinic Staff model
6) Create an appointment structure
7) Develop clinical practice protocol
8) Develop Relationship with Relevant Subspecialties
Heart Failure Patients Operational
Consideration

LHFS
HF patients operational considerations
09) Develop partnership with frequently used clinical services.
10) Develop a Technology & virtual visit infrastructure ( Optional )
11) Establish a Mechanism for patient follow up
12) Create Hospital Coverage Plan
13) Determine mechanism for continuous Quality Improvement
14) Obtain Appropriate Accreditations .JCI ,AHA & ACC (Optional )
15) build or join Research Network
16) Develop Business Plan.
Heart Failure Patients Operational
Consideration

LHFS
Specific Patient Population
1) We have three to four levels of heart failure services like ,
a) Level I Community health care , with only out patient clinics capability
b) Level II , general hospitals with Emergency department, Inpatient and outpatient
services , without Cath lab and PCI .
C) Level III , all as in level 11 but without advanced heart failure therapies (
LVAD/OHT )
d) Level IV , all level three with advanced MDHFP and advanced HF therapies
capability (like ICD/CRTD/MV clip/LVAD & heart transplant ) .
2) Every HF service from level I to III should be prepared to receive stage B and
stage C HF with reduced or preserved EF . Many have comorbidities too.
Since every service has limitations especially level I to III , therefore we need to
develop referral criteria amongst Sindh healthcare cluster & HF network, especially
for early referral ( right patient at right time ) of heart failure stage D.
Specific Patient Population

LHFS
Inter-hospital triggers for referral
1) Recognizing that not all HF practices will directly offer advanced HF
therapies ,so we need friendly referral framework and publicize it
( Like I -NEED- HELP & inter hospital referral criteria forms).
2) We have most of the cardiac services in cardiovascular healthcare cluster
,but services are fragmented & uncoordinated . We have no advanced HF
therapies like heart transplant , mechanical circulatory support devices ( LVAD ) &
no HF palliative care /HF Rehabilitation.
3) In preparation for advanced HF therapies / heart transplant its mandatory
to first build multidisciplinary heart failure programme ( MDHFP ) and
network to connect all services , with cardiac rehabilitation and last not
the least , heart failure teaching ,training of all stakeholders ( physicians
& nurses ) and research indeed .
Inter hospital Triggers for referral

LHFS
Inter-hospital Referral Criteria to MDHFP
1
2
3
4
5
6
7
New onset ( De-Novo ) heart failure , regardless of LVEF for evaluation of HF etiology & precipitating factors
, early initiation of guide-line directed medical therapies ( GDMT ) and prevention of deaths & disabilities .
Chronic heart failure with one of the high risk feature ( see high risk table ) like persistent FC 111 IV symptoms .
Symptomatic hypotension,( < 90 mm ) , Recurrent ER Visits or hospitalization, Major organ dysfunction & others.
To Assist with GDMT like ARNI and comorbid conditions ( like CKD and hyperkalemia )
Persistently reduced EF < 35% despite GDMT for > 3 months for consideration of device therapy.
Second opinion regarding etiology ( Ischemic HF , Valve diseases, cardiomyopathies evaluation )
Annual Review for patients with established advanced HF for evaluation of advanced therapies .
Assess the possibility of participation in clinical trials .
Inter Hospital Referral Criteria to
Multidisciplinary HF Program

LHFS
1
2
3
4
5
6
7
Need for chronic IV Inotropes / IV diuretics
Persistent FC 111 IV symptoms of congestion or profound fatigue .
Symptomatic hypotension, Systolic blood pressure ( < 90 mm )
Recurrent ER Visits or hospitalization for worsening HF ( ADCHF )
Major organ dysfunction Creatnine > 1.8 mg or BUN > 43 , Increasing passive liver congestion ( Hyperbilirubinemia )
Clinical deterioration , persistently raised BNP , increasing breathlessness, Edema ,inability to tolerate GDMT
( ACE,ARB,ARNI, beta blockers & MRA Spironolactone )
High mortality risk need advanced therapies ( Post cardiac arrest survivor)
High risk chronic HF triggers for
referral to MDHFP

LHFS
(I NEED HELP )
Decision making points to refer HF patient for advanced therapy
I
N
E
E
D
H
E
L
P
IV inotropes
NYHA FC III /IV or persistently raised BNP
End Organ Dysfunction ( renal & Liver )
LV Ejection Fraction < 35%
Defibrillator shocks
Hospitalization > 1
Edema despite escalating dose of diuretics
Low blood pressure < 80, tachycardia
Progressive intolerance or down titration of GDMT ( mainly Prognostic medications )
(I NEED HELP )
Decision making points to refer HF patient for advanced therapy

LHFS
Appropriate Leadership
One of the most important decision while organizing a multidisciplinary HF
program amongst stakeholders, is effective leadership.
“Dyad of a HF physician and administrative professional”.
Physician is responsible for ensuring delivery of high quality ,safe ,evidence-
based patient care.
Physician encourages teamwork, maximizes productivity of the clinical team, and
oversees clinician-driven resources use & staffing.
Administrative Leader handles financial and supply chain management , market
share analysis ,informatics infrastructure and medical records maintenance,
billing ,capital planning and deployment.
Appropriate Leadership

LHFS
Determine HF programme staff Model
Along with heart failure physician and assistants ,allied health
professionals are important in ensuring the success of HF program, like
• Clinical pharmacist
• Registered nurse
• Nutritionist
• Psychologist
• Palliative care
• Physical therapist/exercise physiologist
• Social worker
• Financial Coordinator
Advanced HF patients especially with
an implanted hemodynamic
monitoring device, post LVAD and
heart transplant patients, need trained
coordinators
( usually trained nurses ) who provide
ongoing monitoring and support
Determine HF programme
Staff Model

LHFS
HF patients Appointment structure
To make best decisions , the HF team should consider establishing the
total number of patients on different clinics .Visit structure and
duration, time per patient ,may need to be tailored for individual
patients per clinical judgement , as under .
1) New patient appointment ( RAHFC )
2) Established diagnosis and HF stage for drug dose monitoring and
dose titration ( GDMT or maximally tolerated ) at RHFC
3) Post discharge transitional care ,PDHFC ( early with in 2 weeks )
4) Urgent care appointment ( Same day )
5) Group Appointments for HF education /Cardiac rehabilitation classes
Heart Failure Patient Appointment
Structure

How soon should I see Newly
Referred HF Patient
Triage category/
Access target
Clinical Scenario
Emergency with in
24 hours
• Acute severe myocarditis /Cardiogenic Shock
• Transplant & Device evaluation of unstable patient.
• New onset acute Pulmonary Edema
• HF in setting of acute coronary syndromes
Urgent
< 2 Weeks
Progressive /Decompensated heart failure.
*New onset decompensated heart failure.
*New progression to NYHA FC 1V HF.
*Post Myocardial infarction HF/ Post hospitalization HF ER visit.
*Heart Failure with severe valve disease
Semi Urgent < 4 Weeks • New Onset heart failure FC 1 & 11 compensated.
• HF with NYHA class 11 & 111 symptoms
• Worsening HF despite treatment .
• Severe valve disease with mild symptoms with renal impairment or hypotension
Routine schedule 6-12
Weeks
Chronic heart failure FC11
Structural heart disease with NYHA FC 1/ or asymptomatic stage B
How soon should I see
Newly Referred Heart Failure Patient

High Risk HF patients
Follow up every 1-4 weeks /or visits
may increase because of medication
titration.
Intermediate Risk HF patients.
Every 1 to 6 months
Low Risk HF patients
Every 6 -12 months
• Recent HF hospitalization
• NYHA class 111 or 1V symptoms
• New onset heart failure
• During titration of HF medications
• Complications of HF therapy ,like
renal and electrolyte imbalance &
hypotension.
• Need to down titrate or discontinue
beta blockers/ACE or ARB /ARNI
• Severe concomitant and active illness
like COPD exacerbation.
• Frequent ICD shocks /Infections.
No Clear high /low risk features of HF. • No hospitalizations in past one year.
• NYHA Class 1 or 11.
• No recent changes in medications.
• Receiving optimal medical /device
HF therapies.
How Often Should My HF Patient Be Seen .
( Follow up frequency)

Suggested timing for measurement of LV Ejection
Fraction according to scenario.
Clinical
Scenario
Timing of
Measurement
Modality of
Measurement
Comments
New onset HF Immediately or with in 2
weeks as baseline
assessment.
Preferably Echo when
available/ MUGA/CMRI
70% request echo
30% other modalities
according to clinical
judgement
Following titration of triple
therapy. Or for ICD & CRT
implantation.
3 months after
completion of titration
Echo or
MUGA or
CMRI
Preferably same modality
LVEF after GDMT might
improve ,obviating device
therapy.
Stable Heart Failure.
After significant clinical event/HF
admission
2 to 3 years if EF > 40%
With in 30 days during
hospitalization
Echo, MUGA or CMRI.
Echo, MUGA ,CMRI
Or Cath if ACS
For prognostic significance. If
get worse need ICD/CRT.
Helpful for EF, Valve regurgitation &
RV SP.
Suggested timing for measurement of LV Ejection
Fraction according to scenario.

LHFS
Heart failure being a complex syndrome ,therefore these patients should have access to clinical
specialties within and outside of CV medicine .Although patient will be closely followed by HF
physician to maintain primary care relationship, but adequate attention is paid to comorbid
conditions and noncardiovascular preventive care.
1) General Cardiologist / general physician
2) Cardiothoracic surgeon
3) Electrophysiologist
4) Interventional cardiologist
5) Adult congenital Heart disease cardiologist / Cardiac imaging specialist/ Cardiac pathlogist.
Patients with multiple comorbidities will frequently need to consult subspeciality colleagues,
1) Nephrologist , Endocrinologist, pulmonologist ,hematologist & gastro-enterologist
2) Oncologist, Obstetrician, Psychiatrist, Sleep medicine physician, geriatricians & palliative
care providers , General surgery and others.
Develop partnership with relevant
subspecialties

LHFS
HF patients need access to certain services ,in addition to medical and
surgical subspecialties. Several resources and services are also
included,
1) Electrocardiography ( EKG )
2) Echocardiography
3) Cardiac magnetic resonance imaging ( CMRI )
4) Cardiac stress testing & Cardio-pulmonary exercise testing ( CPET ).
5) Cardiac Cath, Coronary angiography ,and coronary and valve intervention.
6) Cardiac Rehabilitation
7) Palliative Care
8) Home nursing care
9) Infusion center / with in clinic , for OPD I/V diuretics and inotropes ( SDHFC )
Develop partnership with frequently
used clinical services

LHFS
Develop technology and Virtual visit
infrastructure
Advances in information technology and virtual visits , our
compensated heart failure patients living in remote areas can benefit
through telecommunication .
This was especially relevant during COVID -19 pandemic , where many
centers had adopted virtual visits for most of the heart failure patients
in efforts to reduce exposure and transmission of infection.
This opportunity taught us many things ,like 60% of our compensated
patients in Makkah heart failure registry ,many of them can be
followed in permanent “ Virtual HF Clinic “ in our MDHFP model of
care.
infrastructure

LHFS
infrastructure
Tele-medicine programs generally include some form of telecommunication between patients
and care providers. It includes objective data acquisition ,such as vital signs, weight and
activity monitoring and last not the least medication adherence.
This telemedicine based intervention on mortality, hospitalization and quality of life end points
, Variable results can be used across clinical trials .
Some heart failure clinics in collaboration with electrophysiologist , may be able to have
infrastructure and staff to monitor data from implanted devices including wireless pulmonary
artery pressure sensor.
Therefore these technologies may assist HF clinics in helping patients to spend more time
safely at home and less time for monitoring in hospital setting.
Many heart failure clinics, particularly EMR software clinical and administrative champions (
Super-users) can drive optimization of electronic medical record in the context of HF clinic
workflows.
infrastructure

LHFS
Establish a mechanism for patient follow-up
Once a patient has established care in multidisciplinary HF programme,
it will be important to determine appropriate follow up intervals.
1) Who should be disposed from MDHFP, Heart failure with recovered LV ejection fraction EF
> 40% , normal BNP level and absence of HF symptoms .
2)HF with improved EF > 40%, but still dilated LV with MR and pulm hypertension,
raised BNP and symptomatic ,should have continue follow up in MDHFP.
3) Heart failure with uncertain prognosis living away from MDHFP ,can have
“ shared care “ in which patient will have follow up with community HF / or with
referring physician and have regular follow up at ( 4-6 months ) MDHFP physician
/Virtual visit to save appointments, travel time at the cost to maintain patient
confidence and relationship.
Establish a mechanism for patient
follow-up

LHFS
4) Stable /compensated HF patients ,who are asymptomatic or minimally
symptomatic can be seen annually to ensure they are receiving optimal
doses of GDMT and are adhering to their medication regimen.
Regardless of an in-person or virtual visit strategy, with periodic labs
monitoring ( Renal profile and electrolytes)
5) Post discharge heart failure follow up ( PDHFC ). All heart failure patients ( De-
novo /or ADCHF/& advanced HF ) are vulnerable for readmission with in 60 days
, HF nurse co-ordinator should call them by phone on 3rd day of
discharge if they are OK and no questions , book them for follow up
appointment with in 7- 14 days after discharge.
follow-up

LHFS
6 ) Same day Clinic without appointment ( SDHFC ) This is a flexible clinic for complex
patients who require frequent follow up under special circumstances ,like those
were seen in emergency department with new onset heart failure and left DAMA
or refused admission or discharged after observation from Observation unit ,
they should have alternative to complete diagnostic work up or continuation of
care and implementation and dose titration of GDMT .
Those in transitional phase of advanced heart failure who require I/V
diuretic or inotropic support can also be seen on this clinic to avoid
visiting Emergency and recurrent hospitalization.
7) New onset HF with mild to moderate symptoms before confirmed diagnosis
are also seen without appointment on rapid access HF clinic ( RAHFC )
follow-up

LHFS
Create a hospital coverage plan
When patients are admitted first time to acute
care hospital ,who are already enrolled in a
programme , HF team is consulted to share in
care during hospitalization .
During transitional care from hospital to home ,
HF nurse will call patient on 3rd day ,if all goes
smoothly then post discharge HF clinic is
booked with in two weeks for continuation of
care and follow up.
Create a Hospital Coverage Plan

LHFS
Determine a mechanism for continuous
Quality improvement
One of the most important aspect of maintaining a successful
multidisciplinary heart failure programme is to ensure continuous
quality improvement .
Quality team should rigorously track objective clinical outcomes ,such
as mortality and hospital admission. Additional quality measures may
include,
*Time from external referral to being seen.* GDMT use and appropriate dose
titration. * Referral for ICD & CRT * Patient satisfaction * Care provider and staff
satisfaction * Post discharge phone on 3rd day * Post discharge early ( 7-14 days )
follow up appointment before discharge* Phone call /electronic communication
those who miss appointment to prevent lost follow up.* HF education delivered
,including patient teach-back and material handouts in local language.
Determine a mechanism for continuous
Quality improvement

LHFS
Performance Measures for Heart Failure
1) LV ejection fraction assessment
2) Symptom and activity assessment
3) Symptom management
4) Beta-blocker therapy for HFrEF
5) ACE/ARB/ARNI therapy for HFrEF
6) ARNI therapy for HFrEF
7) Dose of beta-blocker therapy for HFrEF
8) Dose of ACE,ARB or ARNI therapy for HFrEF
9) MRA therapy for HFrEF
10) Laboratory monitoring for new therapy.
11) Hydralzine/nitrates those can not tolerate ACE.
12) Counseling regarding ICD implant for HFrEF on
GDMT
13) CRT implantation for HFrEF on GDMT
1) NYHA functional classification
assessment with in last 12 months.
2) HF activity recommendation provided.
3) Discussion of advanced directive/ care
planning
4) Advanced directive executed
5) Beta blocker therapy for LV systolic
dysfunction
6) ACE/ARB or ARNI for LV systolic
dysfunction
7) MRA for LV systolic dysfunction
JCI/ American Heart Association advanced Certification in HF
2020 ACC/AHA clinical performance & Quality measures in
Heart Failure .
Performance Measures for Heart Failure

LHFS
Obtain Appropriate Accreditation
Several organizations accredit heart failure clinics and multidisciplinary
programmes like, clinical care programme certification (CCPC )
,including joint commission ( JCI ) the ACC and AHA.
PSCCH Al-ahssa was/is the only one CCPC ,HF center in middle east
accredited in October 2017.( I had a honour to be co-ordinator of this
specialized HF programme to win the certification )
CCPC heart failure need , adhere to standards in domains such as
MDHFP and information management ,clinical care delivery, self-
management education, and continuous quality improvement using
standardized performance measures. We can contact those respective
organizations to initiate the accreditation process.
Obtain Appropriate Accreditation

LHFS
Build a research Network
Randomized clinical trials are foundation of evidence based medicine but
have become increasingly difficult in research world.
Physician scientist especially clinical investigators have been disappearing
breed which is a disturbing trend.
Although direct benefit of research participation extends to both patients
and clinicians.
With the establishment of HF programme ,and Makkah heart failure
registry ,we can promote research awareness and access amongst young
clinicians and HF patients indeed.
To overcome barriers ,we should develop or join existing research network.
Build Research Work

LHFS
Develop a Business Plan
A crucial step in developing a new multidisciplinary HF programme is
constructing a business plan to support the network of specialized clinic and
its goals.
It is worthwhile to consider high-level topics that should be addressed in a
concise business plan, they include
1) Executive summary, in local & plain language to discuss burden of heart
failure in Larkana and in context of fractured health care delivery system.
2) Financial plan that includes projected MDHFP ,the volume of HF patients
and revenue ,as well as expenses including those arising from requisite
staffing.
3) Specific market analysis that highlights the clinical burden and business
opportunity presented by network of HF clinics.
Develop Business Plan

LHFS
Develop a Business Plan
Plan for capture of “ downstream “ business and savings generated by
multidisciplinary heart failure program( MDHFP ) include,
1) Potential reduction in ist admission and readmissions rates
associated with opening of rapid access HF clinics (
RAHFC ) and post discharge HF clinics ( PDHFC ) especially in
vulnerable patients in vulnerable phase ( 60 days) .
2) Increase in procedures like, Cardiac cath-angio and intervention, cardiac
surgeries , Echo, CPET, CMRI & others in right patients at right time.
3) Inter-hospital referrals of advanced HF patients for LVAD and heart
transplant.
Develop Business Plan

LHFS
Conclusions
1) Heart failure continues to be associated with high rates of mortality and
recurrent , prolonged hospitalization, which will have considerable
financial burden on all HF stakeholders.
2) The comprehensive multidisciplinary HF programme and clinic network
across Sindh healthcare cluster will significantly improve quality of
outpatient heart failure care.
3) Going forward, MDHFP & network can serve in the role of a “ hub “ as
advances in technology enable care to be shifted from inpatient to
ambulatory outpatient ( like, I/V diuretic use in SDHFC )
4) To improve quality of care and outcomes ,we need to focus on heart
failure education amongst all stakeholders and heart failure research
indeed.
Conclusion

Conclusion
“ Zigzag/Disorganized ”
In Heart Failure world ,we are facing with these
Tiger ( Small , non dilated & dysfunctional LV ) and Elephant (
Large ,dilated & dysfunctional LV ) hearts with heterogeneous
prognosis.
We spent tons of money on of heart failure care ,yet our
services are Zigzag and fragmented.
We need to review our problems, and work on organized care
of heart failure for better outcome.

Conclusion
“ Zigzag/Disorganized”

LHFS
Refrences
1. CW, Carson AP, et al. Heart disease and stroke statistics-2019update:areport from the American Heart AssociationCirculation2019;139:e56 e528.
2. Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, et al. Forecasting the impact of heart failure
in the United States: a policy statement from the American Heart Association. Circ Heart Fail 2013;6:606–19.
3. Braunstein JB, Anderson GF, Gerstenblith G, Weller W, Niefeld M, Herbert R, et al. Noncardiac comorbidity increases preventable
hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll
4. Cardiol 2003;42:1226–334. Stewart S, Riegel B, Boyd C, Thompson DR, Burrell LM,Carrington MJ, et al. Establishing a pragmatic framework
to
optimise health outcomes in heart failure and multimorbidity (ARISE-HF): a multidisciplinary position statement. Int J Cardiol 2016;212:1–10.
5. Mentz RJ, Kelly JP, von Lueder TG, Voors AA, Lam CS, Cowie MR, et al. Noncardiac comorbidities in heart failure
with reduced versus preserved ejection fraction. J Am Coll Cardiol 2014;64:2281–93.
6. Kociol RD, Peterson ED, Hammill BG, Flynn KE, Heidenreich PA, Pi~na IL, et al. National survey of hospital strategies
to reduce heart failure readmissions: findings from the Get With the Guidelines-Heart Failure registry. Circ Heart Fail 2012;5:680–7.
7. Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y,Walsh MN, et al. Hospital strategies associated with 30-day
readmission rates for patients with heart failure. Circ CardiovascQual Outcomes 2013;6:444–50.
8. Hauptman PJ, Rich MW, Heidenreich PA, Chin J, Cummings N, Dunlap ME, et al. The heart failure clinic: a consensus
statement of the Heart Failure Society of America. JCard Fail 2008;14:801–15.
Refrences

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ZA Bhutto Combind HF program updated.pptx

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