Heart failure (HF) remains one of the leading health problems, with a projected increase in its prevalence in the coming years. Over the past decades, the management of heart failure has significantly evolved, and we currently have therapeutic options of unquestionable benefit and solid scientific evidence that have contributed to reducing morbidity and mortality, improving prognosis, and enhancing the quality of life of our patients. Despite these advances, heart failure patients still face a poor prognosis, with in-hospital mortality of 2–3%, approximately 15–30% at one year, and around 50–75% at five years. Additionally, heart failure care represents a significant portion of healthcare expenditure, largely driven by the management of decompensations, particularly hospital admissions.
A comprehensive view of heart failure treatment should encompass diagnostic and therapeutic approaches as well as the structures involved in their implementation. Furthermore, the coordination between healthcare settings of varying complexity is essential to ensure optimal patient management. This integration allows us to diagnose, educate, support, and treat patients appropriately, ultimately improving their prognosis and quality of life. In my opinion, the key points in heart failure treatment are as follows:
1. Early and accurate diagnosis
The first key point is the accurate diagnosis and appropriate classification of patients. It is essential to utilize available diagnostic tools effectively, including algorithms, risk scores, biomarkers, and imaging techniques, to ensure a timely and precise diagnosis. The goal is not only to determine the presence of heart failure but also to classify its type and identify any underlying conditions that may benefit from specific additional treatments.
2. Treatment Implementation: Heart Failure Units, Multidisciplinary Teams, and Specialized Nursing
After diagnosis, treatment should be initiated according to clinical practice guidelines (CPGs). For heart failure with preserved or mildly reduced ejection fraction (HFpEF/HFmrEF), treatment includes SGLT2 inhibitors (iSGLT2), diuretics, and comorbidity management. In heart failure with reduced ejection fraction (HFrEF), therapy consists of a combination of four pharmacological groups: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor-neprilysin inhibitors (ARNIs), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors. These agents should be introduced simultaneously and as early as possible, taking into account individual patient characteristics and comorbidities.
Regardless of heart failure type, cardiac rehabilitation should always be incorporated, as it holds the highest level of recommendation in clinical guidelines. Additionally, educating patients and caregivers about the disease and its treatment is crucial, fostering patient empowerment and engagement throughout the care process.
Specialized nursing plays a critical role in all these aspects, particularly in patient education and medication titration. The increasing prevalence of comorbidities in heart failure patients necessitates the involvement of multidisciplinary teams, enabling personalized care and facilitating the implementation of guideline-directed therapies. Heart failure units help standardize diagnosis, optimize treatment, and provide comprehensive, coordinated care throughout the disease course.
3. Continuous Treatment Optimization
Another essential aspect is regular patient assessment to detect disease progression and optimize treatment. This includes reevaluating the introduction of new beneficial medications for specific patient profiles, considering the implantation of devices, coronary revascularization procedures, or valvular repair interventions.
In cases of advanced heart failure, options such as heart transplantation or long-term ventricular assist devices should be considered, alongside palliative care, which should be implemented earlier than it typically is.
This optimization requires close collaboration among different specialists, detailed assessment of complementary tests, and a structured and coordinated follow-up. Decision-making should be consensus-based, well-reasoned, and conducted within multidisciplinary committees. Additionally, patient empowerment is crucial—patients should be well-informed, understand their condition, and actively participate in shared decision-making throughout their treatment journey.
4. Structured Management of Decompensation and Early Detection
Most hospital admissions for heart failure are due to congestive decompensation, and persistent subclinical congestion is associated with worse outcomes. In recent years, structured approaches to diuretic management and precise assessment of residual congestion have been developed to improve decompensation management.
Equally important to treating decompensation effectively is detecting it early and, ideally, preventing it. Telemedicine, pulmonary pressure sensors, and multiparametric algorithms derived from cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillators (ICDs) offer various alternatives for early detection and intervention, aiming to prevent hospital admissions and emergency visits.
A thorough understanding of the characteristics and limitations of these systems is necessary to integrate them into clinical practice. Additionally, strategies should be in place to ensure prompt management once decompensation is detected, minimizing its impact on prognosis and quality of life.
5. Coordinated Care: Hub-and-Spoke Model
Heart failure units not only facilitate standardized and multidisciplinary care but also improve coordination across different levels of healthcare. The hub-and-spoke model of care organization enables optimal treatment access, ensuring that patients who could benefit from advanced therapies receive them.
Effective communication between the hub (a high-complexity center offering advanced treatments) and its spoke centers (referral hospitals) is crucial. This requires well-defined referral protocols tailored to each region’s geographic and resource-specific considerations.
Additionally, there is a need for continued progress in the palliative care of heart failure patients. While significant strides have been made in identifying patients with advanced heart failure, comprehensive palliative care strategies that accompany patients throughout their disease course—rather than being limited to the end stages—are still lacking.
6. Prevention and Early Detection of Heart Failure
The final key point is heart failure prevention. Many individuals are at risk of developing heart failure, with some exhibiting only risk factors while others already have structural or functional cardiac abnormalities without symptoms.
This represents a major population health challenge and a crucial area of research, as early intervention could modify disease progression and prevent the onset of symptomatic heart failure.
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