Long-term management of chronic heart failure patients in internal medicine

  • Anna BelfioreEmail author
  • Vincenzo Ostilio Palmieri
  • Carla Di Gennaro
  • Enrica Settimo
  • Maria Grazia De Sario
  • Stefania Lattanzio
  • Margherita Fanelli
  • Piero Portincasa


Chronic heart failure (CHF) is one of the main disabilities in elderly patients requiring frequent hospitalizations with high health care costs. We studied the outcome of CHF outpatient management in reducing hospitalization after discharge from a division of Internal Medicine at a large 3rd referral regional Hospital. 147 CHF inpatients (M:F: 63:84; mean age 76 ± 9.6 years) admitted for acute exacerbation of CHF were followed up as outpatients at 1, 6, 12 and 24 months after discharge. At baseline, patients underwent: laboratory tests, ECG, echocardiogram and a dedicated-intensive health care educational program involving also their families. The rate of hospitalization in the same group of patients was compared with data from the previous 24 months, a period when patients had been seen elsewhere without disease management programs. Patients had high prevalence of comorbidities and the majority was in NYHA class III or IV. Hypertension and valvular heart disease were the most common causes for CHF. Systolic function was preserved (LVEF ≥ 50%) in 61.9% of cases. Functional NYHA class improved significantly after 6 months and remained stable at 24 months. There was a significant increase in the use of the renin–angiotensin system blockers, beta-blockers and diuretics compared to admission to the ward. At 24 months, hospital readmissions were decreased by 42% as compared to the previous 24 months. Risk factors for re-hospitalizations were anemia, NYHA class III or IV and previous hospitalizations. Establishing an intensive outpatient management program for CHF patients leads to long-term beneficial effects with improved clinical parameters and decreased hospitalization in the setting of Internal Medicine.


Chronic heart failure Disease management Elderly patients Re-hospitalization 


Compliance with Ethical Statement

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional or national research committee and with the1964 Helenski declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from the patient included in the case report.


  1. 1.
    Blecker S, Paul M, Taksler G, Ogedegbe G, Katz S (2013) Heart failure-associeted hospitalizations in the Unites States. J Am Coll Cardiol 61:1259–1267CrossRefGoogle Scholar
  2. 2.
    Rapporto annuale sull’attività di ricovero ospedaliero (2015) Dati SDO 2014. Ministero della Salute, GiugnoGoogle Scholar
  3. 3.
    Philips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR (2004) Comprehensive discharge planning with post discharge support for older patients with congestive heart failure: a meta-analysis. JAMA 291(11):1358–1367CrossRefGoogle Scholar
  4. 4.
    Tavazzi L, Maggioni AP, Lucci D, Cacciatore G, Ansalone G, Oliva F, Porcu M, Italian survey on Acute Heart Failure Investigators (2006) Nationwide survey on acute heart failure in cardiology ward service in Italy. Eur Heart J 27(10):1207–1215CrossRefGoogle Scholar
  5. 5.
    Joynt KE, Jha AK (2011) Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circ Cardiovasc Qual Outcomes 4:53–59CrossRefGoogle Scholar
  6. 6.
    Maggioni AP, Dahlström U, Flippatos G, Chioncel O, Leiro MC, Drozdz J, Fruhwald F et al (2013) EURObservational Research Programme: regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot). Eur J Heart Fail 15:808–817CrossRefGoogle Scholar
  7. 7.
    Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM et al (2008) Factors identified as precipitating hospital admissions for heart failure and clinical outcomes. Findings From OPTIMIZE-HF. Arch Intern Med 168(8):847–854CrossRefGoogle Scholar
  8. 8.
    Zaya M, Phan A, Schwarz ER (2012) Predictors of re-hospitalization in patients with chronic heart failure. World J Cardiol. 4(2):23–30CrossRefGoogle Scholar
  9. 9.
    Desai AS, Stevenson LW (2012) Rehospitalization for heart failure. Predict or prevent? Circulation 126:501–506CrossRefGoogle Scholar
  10. 10.
    Gustafsson F, Malcolm J, Arnold O (2004) Heart failure clinics and outpatient management: review of the evidence and call for quality assurance. Eur Heart J 25:1596–1604CrossRefGoogle Scholar
  11. 11.
    Berg GD, Wadhwa S, Johnson AE (2004) A matched-cohort study of health services utilization and financial outcomes for a heart failure disease-management program in elderly patients. J Am Geriatr Soc 52:1655–1661CrossRefGoogle Scholar
  12. 12.
    Yu DS, Thompson DR, Lee DT (2006) Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcoms. Eur Heart J 27:596–612CrossRefGoogle Scholar
  13. 13.
    Bocchi EA, Cruz F, Guimarães G, Pinho Moreira LF, Issa VS, Ayub Ferreira SM, Chizzola PR, Souza GE, Brandão S, Bacal F (2008) Long-term prospective, randomized, controlled study using repetitive education at six-months intervals and monitoring for adherence in heart failure outpatients: the REMADHE trial. Circ Heart Fail 1:115–124CrossRefGoogle Scholar
  14. 14.
    McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V et al (2012) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. The Task Force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 33(14):1787–1847CrossRefGoogle Scholar
  15. 15.
    Philbin EF, Jenkins PL (2000) Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: analysis of a large, statewide database. Am Heart J 139(3):491–496CrossRefGoogle Scholar
  16. 16.
    Gonzáles-Juanatey JR, Ezquerra EA, Martínez VB, Gutiérrez PC, Nocito AS, Fradera IZ (2008) Heart Failure in outpatients: comorbidities and management by different specialists. The EPISERVE Study. Rev Esp Cardiol 61(6):611–619CrossRefGoogle Scholar
  17. 17.
    Parrinello G, Torres D, Paterna S, Di Pasquale P, Trapanese C, Cardillo M, Bellanca M, Fasullo S, Licata G (2013) Early and personalized ambulatory follow-up to tailor furosemide and fluid intake according to congestion in post-discharge heart failure. Intern Emerg Med 8:221–228CrossRefGoogle Scholar
  18. 18.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH et al (2005) Recommendations for Chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association of Echocardiography, a Branch of the European Society of Cardiology. J Am Soc Echocardiogr 18:1440–1463CrossRefGoogle Scholar
  19. 19.
    De Simone G, Daniels SR, Devereux RB, Meyer RA, Roman MJ, de Divitiis O, Alderman MH (1992) Left ventricular mass and body size in normotensive children and adults: assessment of allometric relations and impact of overweight. J Am Coll Cardiol 20:1251–1260CrossRefGoogle Scholar
  20. 20.
    Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA, Badano L, Zamorano JL (2013) Scientific Document Committee of the European Association of Cardiovascular Imaging. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 14:611–644CrossRefGoogle Scholar
  21. 21.
    Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiňones M (2009) Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eu J Echocardiography 10:1–25CrossRefGoogle Scholar
  22. 22.
    Bennett JA, Riegel B, Bittner V, Nichols J (2002) Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease. Heart Lung 31:262–270CrossRefGoogle Scholar
  23. 23.
    American Diabetes Association (2011) Standards of medical care in diabetes. Diabetes Care 34(Suppl 1):S11–S61CrossRefGoogle Scholar
  24. 24.
    Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, Christiaens T et al (2013) ESH/ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of cardiology (ESC). J Hyperten 31:1281–1357CrossRefGoogle Scholar
  25. 25.
    Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron. 16:31–41CrossRefGoogle Scholar
  26. 26.
    Izaks GJ, Westendorp RG, Knook DL (1999) The definition of anemia in older persons. JAMA 281:1714–1717CrossRefGoogle Scholar
  27. 27.
    McAlister FA, Stewart S, Ferrua S, McMurray JJ (2004) Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 44(4):810–819Google Scholar
  28. 28.
    Roccaforte R, Demers C, Baldassarre F, Teo KK, Yusuf S (2005) Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. Eur J Heart Fail 7:1133–1144CrossRefGoogle Scholar
  29. 29.
    Jaarsma T, van der Wal MH, Lesman-Leegte I, Luttik ML, Hogenhuis J, Veeger NJ, Sanderman R et al (2008) Effect of moderate or intensive disease management program on outcome in patients with heart failure: coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Arch Intern Med 168:316–324CrossRefGoogle Scholar
  30. 30.
    Albert NM, Barnason S, Deswal A, Hernandez A, Kocial R, Lee E, Paul S, Ryan CJ, White-Willianms C and on behalf of the American Heart Association Complex Cardiovascular Patient and family Care Committee of the Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology and Council on Quality of Care and Outcomes Research (2015) Transitions of care in heart failure. A scientific statement from the American Heart Association. Circ Heart Fail 8:384–409CrossRefGoogle Scholar
  31. 31.
    Desai AS (2016) Intensive management to reduce hospitalizations in patients with heart failure. Circulation 133:1704–1707CrossRefGoogle Scholar
  32. 32.
    Huntley AL, Johnson R, King A, Morris RW, Purdy S (2016) Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis. BMJ Open 6:e010933CrossRefGoogle Scholar
  33. 33.
    Bellotti P, Badano LP, Acquarone N, Griffo R, Lo Pinto G, Maggioni AP, Mattiauda C, Menardo G, Mombelloni P, OSCUR Investigators (2001) Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study. Outcome dello Scompenso Cardiaco in relazione all’Utilizzo delle Risorse. Eur Heart J 22(7):596–604CrossRefGoogle Scholar
  34. 34.
    Di Lenarda A, Scherillo M, Maggioni AP, Acquarone N, Ambrosio GB, Annicchiarico M, Bellis P, TEMISTOCLE Investigators et al (2003) Current presentation and management of heart failure in cardiology and internal medicine hospital units: a tale of two worlds-the TEMISTOCLE study. Am Heart J 146:e12CrossRefGoogle Scholar
  35. 35.
    Biagi P, Gussoni G, Iori I, Nardi R, Mathieu G, Mazzone A, Panuccio D, Scanelli G, Cicatello C, Rinollo C, Muriago M, Galasso D, Bonizzoni E, Vescovo G, CONFINE Study Group (2011) Clinical profile and predictors of in-hospital outcome in patients with heart failure: the FADOI “CONFINE” Study. Int J Cardiol 152:88–94CrossRefGoogle Scholar
  36. 36.
    Havranek EP, Masoudi FA, Westfall KA, Wolfe P, Ordin DL, Krumholz HM (2002) Spectrum of heart failure in older patients results from the National Heart Failure Project. Am Heart J 143:412–417CrossRefGoogle Scholar
  37. 37.
    Sochalski J, Jaarsma T, Krumholz HM, Laramee A, McMurray JJ, Naylor MD, Rich MW, Riegel B, Stewart S (2009) What works in chronic care management: the case of heart failure. Health Aff 28:179–189CrossRefGoogle Scholar
  38. 38.
    Ruppar TM, Cooper PS, Meher DR, Delgado JM, Dunbar-Jacob JM (2016) Medication adherence interventions improve heart failure mortality and readmission rates. J Am Heart Assoc 5(6):e002606CrossRefGoogle Scholar
  39. 39.
    Unverzagt S, Meyer G, Mittmann S, Samos FA, Unverzagt M, Prondzinsky R (2016) Improving treatment adherence in heart failure a systematic review and meta-analysis of pharmacological and lifestyle interventions. Dtsch Arztebl Int 113(25):423–430Google Scholar
  40. 40.
    Maggioni AP, Anker SD, Dahlström U, Filippatos G, Ponikowski P, Zannad F, Amir O, Heart Failure Association of the ESC et al (2013) Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines. Evidence from 12440 patients of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail 15:1173–1184CrossRefGoogle Scholar
  41. 41.
    Komajda M, Hanon O, Hochadel M, Follath F, Swedberg K, Gitt A, Cleland JG (2007) Management of octogenarians hospitalized for heart failure in Euro Heart Failure Survey I. Eur Heart J 28:1310–1318CrossRefGoogle Scholar
  42. 42.
    Gonseth J, Guallar-Castillón P, Banegas JR, Rodríguez-Artalejo F (2004) The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J 25:1570–1595CrossRefGoogle Scholar
  43. 43.
    Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI (2000) Predictors of readmission among elderly survivors of admission with heart failure. Am Heart J 139:72–77CrossRefGoogle Scholar
  44. 44.
    Tsuchihashi M, Tsutsui H, Kodama K, Kasagi F, Setoguchi S, Mohr M, Kubota T, Takeshita A (2001) Medical and socioenvironmental predictors of hospital readmission in patients with congestive heart failure. Am Heart J 142:20A–26ACrossRefGoogle Scholar
  45. 45.
    Zaya M, Phan A, Ernst R, Schwarz ER (2012) Predictors of re-hospitalization in patients with chronic heart failure. World J Cardiol 4:23–30CrossRefGoogle Scholar
  46. 46.
    Somaratne JB, Berry C, McMurray JJ, Poppe KK, Doughty RN, Whalley GA (2009) The prognostic significance of heart failure with preserved left ventricular ejection fraction: a literature-based meta-analysis. Eur J Heart Fail 11:855–862CrossRefGoogle Scholar
  47. 47.
    Berry C, Doughty RN, Granger C, Køber L, Massie B, McAlister F, McMurray J et al (2012) The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis. Meta-analysis Global Group in Heart Failure (MAGGIC). Eur Heart J 33(14):1750–1757CrossRefGoogle Scholar

Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  1. 1.Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human OncologyUniversity of Bari Medical SchoolBariItaly
  2. 2.Biostatistic, Interdisciplinary Department of MedicineUniversity of Bari Medical SchoolBariItaly

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