Current Heart Failure Reports

, Volume 15, Issue 6, pp 357–367 | Cite as

Setting Up a Heart Failure Program in 2018: Moving Towards New Paradigm(s)

  • Nadia Bouabdallaoui
  • Anique DucharmeEmail author
Implementation (L. Rohde, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Implementation


Purpose of Review

Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting.

Recent Findings

Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients’ care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined.


HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.


Chronic heart failure Disease management Heart failure programs Multidisciplinary care Mortality Healthcare cost Quality of care 



Dr Ducharme holds the University of Montreal's Fondation Marcelle et Jean Coutu, Cal et Janine Moisan Chair for improving practices in advanced heart failure.

Compliance with Ethical Standards

Conflict of Interest

Nadia Bouabdallaoui and Anique Ducharme declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance • Of major importance

  1. 1.
    Levy D, Kenchaiah S, Larson MG, Benjamin EJ, Kupka MJ, Ho KK, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med. 2002;347(18):1397–402. Scholar
  2. 2.
    Tsao CW, Lyass A, Enserro D, Larson MG, Ho JE, Kizer JR, Gottdiener JS, Psaty BM, Vasan RS. Temporal trends in the incidence of and mortality associated with heart failure with preserved and reduced ejection fraction. JACC Heart Fail. 2018. pii: S2213–1779(18)30219–1. DOI: PubMedGoogle Scholar
  3. 3.
    Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D'Agostino RB, Kannel WB, et al. Framingham Heart Study. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation. 2002;106(24):3068–72.CrossRefGoogle Scholar
  4. 4.
    Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–e492. Scholar
  5. 5.
    Cook C, Cole G, Asaria P, Jabbour R, Francis DP. The annual global economic burden of heart failure. Int J Cardiol. 2014;171(3):368–76. Scholar
  6. 6.
    Kilgore M, Patel HK, Kielhorn A, Maya JF, Sharma P. Economic burden of hospitalizations of Medicare beneficiaries with heart failure. Risk Manag Healthc Policy. 2017;10:63–70. Scholar
  7. 7.
    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–28. Scholar
  8. 8.
    Salata BM, Sterling MR, Beecy AN, Ullal AV, Jones EC, Horn EM, et al. Discharge processes and 30-day readmission rates of patients hospitalized for heart failure on general medicine and cardiology services. Am J Cardiol. 2018;121(9):1076–80. Scholar
  9. 9.
    Pandey A, Golwala H, Xu H, DeVore AD, Matsouaka R, Pencina M, et al. Association of 30-day readmission metric for heart failure under the hospital readmissions reduction program with quality of care and outcomes. JACC Heart Fail. 2016;4(12):935–46. Scholar
  10. 10.
    Carson PE, Anand IS, Win S, Rector T, Haass M, Lopez-Sendon J, et al. The hospitalization burden and post-hospitalization mortality risk in heart failure with preserved ejection fraction: results from the I-PRESERVE trial (Irbesartan in heart failure and preserved ejection fraction). JACC Heart Fail. 2015;3(6):429–41. Scholar
  11. 11.
    Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333(18):1190–5. Scholar
  12. 12.
    Hauptman PJ, Rich MW, Heidenreich PA, Chin J, Cummings N, Dunlap ME, et al. Heart Failure Society of America. The heart failure clinic: a consensus statement of the Heart Failure Society of America. J Card Fail. 2008;14(10):801–15. Scholar
  13. 13.
    Albert NM, Barnason S, Deswal A, Hernandez A, Kociol R, Lee E, et al. Transitions of care in heart failure: a scientific statement from the American Heart Association. Circ Heart Fail. 2015;8(2):384–409. Scholar
  14. 14.
    Chan DC, Heidenreich PA, Weinstein MC, Fonarow GC. Heart failure disease management programs: a cost-effectiveness analysis. Am Heart J. 2008;155(2):332–8. Scholar
  15. 15.
    Gonseth J, Guallar-Castillón P, Banegas JR, Rodríguez-Artalejo F. 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. 2004;25(18):1570–95. Scholar
  16. 16.
    Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJ, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774–84. Scholar
  17. 17.
    Roccaforte R, Demers C, Baldassarre F, Teo KK, Yusuf S. Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. Eur J Heart Fail. 2005;7(7):1133–44. Scholar
  18. 18.
    • Gandhi S, Mosleh W, Sharma UC, Demers C, Farkouh ME, Schwalm JD. Multidisciplinary heart failure clinics are associated with lower heart failure hospitalization and mortality: systematic review and meta-analysis. Can J Cardiol. 2017;33(10):1237–44. This work is based on the most recently published pooled analyses regarding the beneficial effects of HF programs. It reinforces the role of multidisciplinary programs in reducing the incidence of HF hospitalization and all-cause mortality (OR 0.58; p =0.0003) . It demonstrates that the largest benefit is observed in high-risk patients (those recently admitted to hospital or emergency room). CrossRefPubMedGoogle Scholar
  19. 19.
    • Adamson PB, Abraham WT, Aaron M, Aranda JM Jr, Bourge RC, Smith A, et al. CHAMPION trial rationale and design: the long-term safety and clinical efficacy of a wireless pulmonary artery pressure monitoring system. J Card Fail. 2011;17(1):3–10. This work details the rationale and the design of the CardioMicroElectroMechanical System (Abbott, Austin, TX, USA) Heart Sensor Allows Monitoring of Pressures to Improve Outcomes in New York Heart Association Class III Heart Failure Patients (CHAMPION), that is the first large multicenter single-blinded randomized clinical trial in the setting of invasive monitoring. CrossRefPubMedGoogle Scholar
  20. 20.
    Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients with heart failure. Lancet. 2011;378(9792):731–9. Scholar
  21. 21.
    Frizzell JD, Liang L, Schulte PJ, Yancy CW, Heidenreich PA, Hernandez AF, et al. Prediction of 30-day all-cause readmissions in patients hospitalized for heart failure: comparison of machine learning and other statistical approaches. JAMA Cardiol. 2017;2(2):204–9. Scholar
  22. 22.
    Ducharme A, Doyon O, White M, Rouleau JL, Brophy JM. Impact of care at a multidisciplinary congestive heart failure clinic: a randomized trial. CMAJ. 2005;173(1):40–5. Scholar
  23. 23.
    Rice H, Say R, Betihavas V. The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient Educ Couns. 2018;101(3):363–74. Scholar
  24. 24.
    Smith CE, Piamjariyakul U, Dalton KM, Russell C, Wick J, Ellerbeck EF. Nurse-led multidisciplinary heart failure group clinic appointments: methods, materials, and outcomes used in the clinical trial. J Cardiovasc Nurs. 2015;30(4 Suppl 1):S25–34. Scholar
  25. 25.
    Ezekowitz JA, van Walraven C, McAlister FA, Armstrong PW, Kaul P. Impact of specialist follow-up in outpatients with congestive heart failure. CMAJ. 2005;172(2):189–94. Scholar
  26. 26.
    Smeets M, Van Roy S, Aertgeerts B, Vermandere M, Vaes B. Improving care for heart failure patients in primary care, GPs’ perceptions: a qualitative evidence synthesis. BMJ Open. 2016;6(11):e013459. Scholar
  27. 27.
    Howlett JG. Specialist heart failure clinics must evolve to stay relevant. Can J Cardiol. 2014;30(3):276–80. Scholar
  28. 28.
    Ducharme A. Do heart failure clinics have to reinvent themselves to remain germane? Can J Cardiol. 2017;33(10):1212–4. Scholar
  29. 29.
    Takeda A, Taylor SJ, Taylor RS, Khan F, Krum H, Underwood M. Clinical service organisation for heart failure. Cochrane Database Syst Rev. 2012;9:CD002752. Scholar
  30. 30.
    Stewart S, Carrington MJ, Marwick T, Davidson PM, Macdonald P, Horowitz J, et al. The WHICH? trial: rationale and design of a pragmatic randomized, multicentre comparison of home- vs. clinic-based management of chronic heart failure patients. Eur J Heart Fail. 2011;13(8):909–16. Scholar
  31. 31.
    Stewart S, Carrington MJ, Marwick TH, Davidson PM, Macdonald P, Horowitz JD, et al. Impact of home versus clinic-based management of chronic heart failure: the WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care) multicenter, randomized trial. J Am Coll Cardiol. 2012;60(14):1239–48. Scholar
  32. 32.
    Scuffham PA, Ball J, Horowitz JD, Wong C, Newton PJ, Macdonald P, et al. Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial. Eur Heart J. 2017;38(30):2340–8. Scholar
  33. 33.
    Jaarsma T, van der Wal MH, Lesman-Leegte I, Luttik ML, Hogenhuis J, Veeger NJ, et al. Coordinating study evaluating outcomes of advising and counseling in heart failure (COACH) investigators. 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. 2008;168(3):316–24. Scholar
  34. 34.
    Wijeysundera HC, Machado M, Wang X, Van Der Velde G, Sikich N, Witteman W, et al. Cost-effectiveness of specialized multidisciplinary heart failure clinics in Ontario, Canada. Value Health. 2010;13(8):915–21. Scholar
  35. 35.
    Doughty RN, Wright SP, Pearl A, Walsh HJ, Muncaster S, Whalley GA, et al. Randomized, controlled trial of integrated heart failure management: the Auckland heart failure management study. Eur Heart J. 2002;23(2):139–46. Scholar
  36. 36.
    Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive update of the Canadian cardiovascular society guidelines for the management of heart failure. Can J Cardiol. 2017;33(11):1342–1433. DOI: Scholar
  37. 37.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776–803. DOI: Scholar
  38. 38.
    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891–975. Scholar
  39. 39.
    Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010;8:CD007228. Scholar
  40. 40.
    Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363(24):2301–9. Scholar
  41. 41.
    Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Böhm M, et al. Telemedical Interventional Monitoring in Heart Failure Investigators. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation. 2011;123(17):1873–80. Scholar
  42. 42.
    Ong MK, Romano PS, Edgington S, Aronow HU, Auerbach AD, Black JT, De Marco T, Escarce JJ, Evangelista LS, Hanna B, Ganiats TG, Greenberg BH, Greenfield S, Kaplan SH, Kimchi A, Liu H, Lombardo D, Mangione CM, Sadeghi B, Sadeghi B, Sarrafzadeh M, Tong K, Fonarow GC; Better Effectiveness After Transition–Heart Failure (BEAT-HF) Research Group. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the better effectiveness after transition-heart failure (BEAT-HF) randomized clinical trial. JAMA Intern Med 2016;176(3):310–318. DOI: Scholar
  43. 43.
    Desai AS, Stevenson LW. Connecting the circle from home to heart-failure disease management. N Engl J Med. 2010;363(24):2364–7. Scholar
  44. 44.
    Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation. 2008;118(14):1433–41. Scholar
  45. 45.
    Conraads VM, Tavazzi L, Santini M, Oliva F, Gerritse B, Yu CM, et al. Sensitivity and positive predictive value of implantable intrathoracic impedance monitoring as a predictor of heart failure hospitalizations: the SENSE-HF trial. Eur Heart J. 2011;32(18):2266–73. Scholar
  46. 46.
    van Veldhuisen DJ, Braunschweig F, Conraads V, Ford I, Cowie MR, Jondeau G, et al. Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation. 2011;124(16):1719–26. Scholar
  47. 47.
    Boehmer JP, Hariharan R, Devecchi FG, Smith AL, Molon G, Capucci A, et al. A multisensor algorithm predicts heart failure events in patients with implanted devices. Results From the MultiSENSE Study JACC Heart Fail. 2017;5(3):216–25. Scholar
  48. 48.
    Desai AS, Bhimaraj A, Bharmi R, Jermyn R, Bhatt K, Shavelle D, et al. Ambulatory hemodynamic monitoring reduces heart failure hospitalizations in “real-world” clinical practice. J Am Coll Cardiol. 2017;69(19):2357–65. Scholar
  49. 49.
    Givertz MM, Stevenson LW, Costanzo MR, Bourge RC, Bauman JG, Ginn G, et al. Pulmonary artery pressure-guided management of patients with heart failure and reduced ejection fraction. J Am Coll Cardiol. 2017;70(15):1875–86. Scholar
  50. 50.
    • Abraham WT, Adamson PB, Bourge RC, Aaron MF, Costanzo MR, Stevenson LW, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet. 2011;377(9766):658–66. This work details the results from the CHAMPION trial, in which invasive ambulatory PAP monitoring led to a significant reduction in HF admission 6 months after device implantation in comparison with usual care (HR 0.70, 95% CI 0.60–0.84, p < 0.0001), with no significant rate of device-related complications. CrossRefPubMedGoogle Scholar
  51. 51.
    Abraham WT, Stevenson LW, Bourge RC, Lindenfeld JA, Bauman JG, Adamson PB, et al. Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial. Lancet. 2016;387(10017):453–61. Scholar
  52. 52.
    Adamson PB, Abraham WT, Stevenson LW, Desai AS, Lindenfeld J, Bourge RC, et al. Pulmonary artery pressure-guided heart failure management reduces 30-day readmissions. Circ Heart Fail. 2016;9(6).
  53. 53.
    Adamson PB, Abraham WT, Bourge RC, Costanzo MR, Hasan A, Yadav C, et al. Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction. Circ Heart Fail. 2014;7(6):935–44. Scholar
  54. 54.
    Maurer MS, Adamson PB, Costanzo MR, Eigler N, Gilbert J, Gold MR, et al. Rationale and design of the left atrial pressure monitoring to optimize heart failure therapy study (LAPTOP-HF). J Card Fail. 2015;21(6):479–88. Scholar
  55. 55.
    Abraham WT, Adamson PB, Costanzo MR, Eigler N, Gold M, Klapholz M, et al. Hemodynamic monitoring in advanced heart failure: results from the LAPTOP-HF trial. J Card Fail. 2016;22(11):940. Scholar
  56. 56.
    Hemingway H, Asselbergs FW, Danesh J, Dobson R, Maniadakis N, Maggioni A, et al. Big data from electronic health records for early and late translational cardiovascular research: challenges and potential. Eur Heart J. 2018;39(16):1481–95. Scholar
  57. 57.
    Weber GM. Using artificial intelligence in an intelligent way to improve efficiency of a heart failure care team. J Card Fail 2018. pii: S1071–9164(18)30144–1. DOI: CrossRefGoogle Scholar
  58. 58.
    Evans RS, Benuzillo J, Horne BD, Lloyd JF, Bradshaw A, Budge D, et al. Automated identification and predictive tools to help identify high-risk heart failure patients: pilot evaluation. J Am Med Inform Assoc. 2016;23(5):872–8. Scholar
  59. 59.
    Mortazavi BJ, Downing NS, Bucholz EM, Dharmarajan K, Manhapra A, Li SX, et al. Analysis of machine learning techniques for heart failure readmissions. Circ Cardiovasc Qual Outcomes. 2016;9(6):629–40. Scholar
  60. 60.
    Abrahamyan L, Trubiani G, Witteman W, Mitsakakis N, Krahn M, Wijeysundera HC. Insights into the contemporary management of heart failure in specialized multidisciplinary ambulatory clinics. Can J Cardiol. 2013;29(9):1062–8. Scholar
  61. 61.
    Schou M, Gustafsson F, Videbaek L, Tuxen C, Keller N, Handberg J, et al. NorthStar investigators, all members of The Danish Heart Failure Clinics Network. Extended heart failure clinic follow-up in low-risk patients: a randomized clinical trial (NorthStar). Eur Heart J. 2013;34(6):432–42. Scholar
  62. 62.
    McCall N, Cromwell J. Results of the Medicare health support disease-management pilot program. N Engl J Med. 2011;365(18):1704–12. Scholar
  63. 63.
    Galbreath AD, Krasuski RA, Smith B, Stajduhar KC, Kwan MD, Ellis R, et al. Long-term healthcare and cost outcomes of disease management in a large, randomized, community-based population with heart failure. Circulation. 2004;110(23):3518–26. Scholar
  64. 64.
    McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004;44(4):810–9. Scholar
  65. 65.
    Capomolla S, Febo O, Ceresa M, Caporotondi A, Guazzotti G, La Rovere M, Ferrari M, Lenta F, Baldin S, Vaccarini C, Gnemmi M, Pinna G, Maestri R, Abelli P, Verdirosi S, Cobelli F. Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care. J Am Coll Cardiol 2002;40(7):1259–1266.CrossRefGoogle Scholar
  66. 66.
    Virani SA, Bains M, Code J, Ducharme A, Harkness K, Howlett JG, et al. The need for heart failure advocacy in Canada. Can J Cardiol. 2017;33(11):1450–4. Scholar
  67. 67.
    Hayes SM, Peloquin S, Howlett JG, Harkness K, Giannetti N, Rancourt C, et al. A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future? BMC Health Serv Res. 2015;15:290. Scholar
  68. 68.
    Drewes HW, Steuten LM, Lemmens LC, Baan CA, Boshuizen HC, Elissen AM, et al. The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes. Health Serv Res. 2012;47(5):1926–59. Scholar
  69. 69.
    Martineau P, Frenette M, Blais L, Sauvé C. Multidisciplinary outpatient congestive heart failure clinic: impact on hospital admissions and emergency room visits. Can J Cardiol. 2004;20(12):1205–11.PubMedGoogle Scholar
  70. 70.
    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 Cardiol. 2003;42(7):1226–33.CrossRefGoogle Scholar
  71. 71.
    Richards T, Montori VM, Godlee F, Lapsley P, Paul D. Let the patient revolution begin. BMJ. 2013;346:f2614. Scholar
  72. 72.
    Bekelman DB, Plomondon ME, Carey EP, Sullivan MD, Nelson KM, Hattler B, et al. Primary results of the patient-centered disease management (PCDM) for heart failure study: a randomized clinical trial. JAMA Intern Med. 2015;175(5):725–32. Scholar

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Authors and Affiliations

  1. 1.Department of Medicine, Montreal Heart InstituteUniversité de MontréalMontrealCanada

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