building HF program in Pakistan Unique heart failure manual part I to III , dedicated to Shaheed ZA Bhutto

1. 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

2. Shaheed Zulfiqar Ali Bhutto
First Multidisciplinary Value based Heart Failure
Program & network Sindh Pakistan.
“GDMT Shift from inpatient to ambulatory outpatient Setting “

3. Part III
Shaheed Zulfiqar Ali Bhutto
First Multidisciplinary Value based Heart Failure
Program & network Sindh Pakistan.
Patients Operational
Consideration

4. 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

5. 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
Heart Failure Programme
Multidisciplinary Team

6. 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

7. 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

8. 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 , KAMC ,all level three with advanced MDHFP and advanced HF
therapies capability (like ICD/CRTD/MV clip/LVAD & heart transplant ) .
2) Every HF service 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 Makkah healthcare cluster & HF network,
especially early referral of heart failure stage D.
Specific Patient Population

9. 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 & referral criteria tables).
2) We have all the services in Holy Makkah healthcare cluster except
heart transplant & Cardiac /HF
Rehabilitation.
3) In preparation for heart transplant its mandatory to have
multidisciplinary heart failure programme ( MDHFP ) and network
to connect all services , with cardiac rehabilitation and last not the
least , heart failure teaching ,training ( physicians & nurses )
and research .
Inter hospital Triggers for referral

10. 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 etiology & GDMT disease management
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 )
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
MDHFP

11. 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
MDHFP

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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.

19. 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

20. 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

21. 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.
Develop technology and Virtual visit
infrastructure

22. LHFS
Develop technology and Virtual visit
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.
Develop technology and Virtual visit
infrastructure

23. 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

24. LHFS
Establish a mechanism for patient follow-up
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.
Establish a mechanism for patient
follow-up

25. LHFS
Establish a mechanism for patient follow-up
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 )
Establish a mechanism for patient
follow-up

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. LHFS
Conclusions
1) Heart failure continues to be associated with high rates of
mortality and recurrent , prolonged hospitalization,
which will have considerable 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

34. 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.

35. Conclusion
“ Zigzag/Disorganized”

36. LHFS
Refrences
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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
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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

37. THANK YOU
Living Longer, Living Well