ZA Bhutto Heart Failure program manual Part I.

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 “

Building First multidisciplinary
Heart Failure Clinic/
Programme ( MDHFP/CCPC )
, sindh Pakistan.
Part I - III

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 to Clinical care Heart Failure
Programme ( CCPC ) First in middle East October 2017.
It was not just a 6 months game but my journey started while working as head of cardiology in King Fahad hospital Hofuf,
Being first physician, to join PSCCH,I alone screened all the cardiac patients from King Fahad hospital , and registered them
on specialized clinics ,like adult congenital heart ,Valve disease and heart failure clinic indeed. 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
He 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 iontrops and
expired on same day at 7.50 am ( with in 9-10 hours of admission ) .
After 8 years journey , Last case he 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 ionotropic 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

Heart Failure Facts
64
million
64 million patients worldwide are living with HF,
( 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 with
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

Improving Heart Failure
Services for people in Larkana
Building Multidisciplinary
Heart Failure Programme
( MDHFP )
and network
In Sindh Pakistan.
Part I
Improving Heart Failure
Services for people in Sindh /Pakistan

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-obstetric heart failure Clinic .
2) Implementation and monitoring of updated
guidelines on heart failure diagnosis and management.
Aims of the Multidisciplinary value based Heart Failure
Programme

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 .
Aims of the Multidisciplinary value based Heart Failure
Programme

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.
Aims of the Multidisciplinary
Value based Heart Failure Programme

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
Multidisciplinary Value based
Heart Failure Programme

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 high
performing MDHFP / clinics .
This document was developed to empower dedicated physicians ,who
wish to build and sustain state of art multidisciplinary heart
failure programme & Network.

Steps to build
Multidisciplinary Heart Failure Program in Sindh /Pakistan
“ Patient Care Consideration “
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 of 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 Novel Heart Failure
Clinics , Sindh/Pakistan

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 in
“ 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 )
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

ZA Bhutto Heart Failure program manual Part I.

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ZA Bhutto Heart Failure program manual Part I.