build Heart Failure program & network in Sindh Pakistan .

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. Building First multidisciplinary Heart Failure Clinic/
Programme ( MDHFP/CCPC )
, sindh Pakistan.
“ Patient Care Consideration “
Part II
Shaheed Zulfiqar Ali Bhutto
First Multidisciplinary value based Heart Failure
Program & network Sindh Pakistan.

4. 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.

5. Improving Heart Failure
Services for people in Larkana
Building Multidisciplinary
Heart Failure Programme
( 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.

6. 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.
Need for MDHF Programme

7. 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

8. 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

9. 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
HF Patient Care Consideration

10. 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 Multidisciplinary Heart Failure Program
( MDHFP )

11. 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 HF Patient ( De-Novo ) Evaluation

13. 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

14. 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

15. 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
Medical Therapy Evaluation

16. LHFS
Medical Therapy Evaluation
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.
Medical Therapy Evaluation

17. 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

18. 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

19. 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.
Functional Status Assessment

20. LHFS
Functional Status Assessment
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.
Functional Status Assessment

21. 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.
Quality of Life Assessment

22. LHFS
Quality of Life Assessment
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.
Quality of Life Assessment

23. 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

24. 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

25. 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