Advanced heart failure outpatient clinic
Advanced heart failure outpatient clinic
Cardiology and Cardiovascular Medicine Unit
The increase in the mean age of the population and the use of current recommended cardioactive pharmacological therapies in heart failure (HF) resulted in a steady increase in the number of patients with advanced HF. Heart transplant remains the most valid therapeutic choice in this patient category, but in the last decade we have witnessed a progressive reduction in the number of available donors and a parallel increase in their average age. On the one hand, this scenario has led to a reduction in the annual number of transplants and a lengthening of the waiting list time, and on the other, it has stimulated research into new treatment strategies, such as mechanical ventricular assist devices.
The category of patients with advanced HF requires close clinical follow-up, as well as evaluation by a multidisciplinary team composed of different professionals (clinical cardiologists, haemodynamics specialists, electrophysiologists, psychiatrists, psychologists, palliative care doctors, and nurses specialised in HF). In the management of advanced HF, it is essential to define goals of care (GoC) and establish advanced care planning (ACP). In this context, integration with the palliative care (PC) pathway is necessary; unlike the meaning attributed to it in the past, i.e. aimed at the relief of pain and suffering in the last weeks of life, its validated efficacy now envisages involvement from the outset, in association with the various clinical practices and tailored therapy in varying proportions as the disease progresses. In the pursuit of all these goals, the patient and family members (caregivers) are to be considered as a single entity, so fundamental attention for the success of care must be paid to both, to their needs and to the issues raised by them.
The task of the multidisciplinary team is also to be able to establish the optimal timing for possible eligibility for cardiac transplantation (with early referral to the Transplant Centre in Siena) or implantation of a ventricular assist device (performed at our centre, FTGM Massa and Pisa).
The clinical course of HF patients involves an inexorable cascade of events that in most cases involves repeated hospitalisations with the need for cycles of inotropic therapy up to end-stage heart failure refractory to therapy.
In the subgroup of patients who could benefit from a left ventricular assist device (LVAD), the selection of the most appropriate therapeutic window for implantation constitutes the most difficult hurdle for the clinical cardiologist to face; in particular, the assessment of right ventricular function requires advanced skills and specific instrumental techniques (3D echocardiography, right ventricular strain) and represents one of the main limiting elements for possible eligibility. A delay in assessment translates to the loss of the only chance to treat such patients with advanced HF who have exceeded the age for eligibility for transplantation or have absolute contraindications to this treatment.
In light of these considerations, the need arises for a dedicated outpatient clinic to allow constant monitoring in this category of patients and to establish a network with local cardiology and surrounding hospitals that do not offer the possibility of such therapies.
The advanced heart failure outpatient clinic will be dedicated to patients with severe left ventricular systolic dysfunction (EF < 30%), symptomatic for dyspnoea (NYHA class IIb or higher) reduced functional capacity (as assessed by cardiopulmonary test or 6-minute walking test) and recent hospitalisation for heart failure exacerbation with clinical signs of low flow rate or with a clinical picture of volume overload (at least the second admission in the last 12 months or frequent flyers) or patients with severe left ventricular systolic dysfunction (first diagnosis made in the context of cardiogenic shock or with poor chances of recovery); such patients will be referred by the Foundation’s internal or external physicians with a view to entering into a pathway of close clinical and instrumental follow-up and with the plan to be promptly referred to the transplant/left ventricular assist pathway. Finally, patients who have already undergone left ventricular assist implantation or cardiac transplantation will also be referred to this outpatient clinic to ensure appropriate cardiological follow-up.
The purpose of the outpatient clinic is to provide a formal and preferential channel of reference for the management and care of this category of complex patients who require constant surveillance and multi-specialist evaluation in order to be able to assess the most appropriate timing for eligibility for the various treatments, as well as integration with the palliative care pathway. The project also envisages a close counselling network with Colleagues in Siena for the possible need of a cardiac transplant, with Colleagues in the Massa facility for possible left ventricular assist implantation and with regional services, in particular with the home nursing service specialised in HF.
Composition of the FTGM Pisa-Massamultidisciplinary team:
Cardiologists: Dr Andrea Barison, Dr Vladyslav Chubuchnyi, Dr Iacopo Fabiani, Dr Alessandra Gabutti, Dr Alberto Giannoni, Dr Chrysanthos Grigoratos, Dr Emilio Maria Pasanisi, Prof. Claudio Passino, Dr Cristina Petersen, Dr Roberta Poletti, Dr Simone Sorbo, Dr Valentina Spini, Dr Alessandro Valleggi, Dr Giuseppe Vergaro
Interventional cardiologist: Dr Luigi Pastormerlo
Electrophysiologists: Dr Luca Panchetti, Dr Gianluca Mirizzi, Dr Marcello Piacenti
Cardiac Surgeons: Dr Giacomo Bianchi, Dr Marco Solinas
Cardioanaesthesiologists: Dr Dorela Haxhiademi, Dr Paolo Del Sarto
Heart failure nurses: Assunta Agazio, Eleonora Benelli, Marco Vaselli
Physiotherapist: Silvia Severino
External advisors
Psychiatrist Dr Laura Palagini
Siena Transplant Centre Dr Sonia Bernazzali
Palliative care specialist Dr Angela Gioia
Local nurses
The advanced heart failure outpatient clinic will be dedicated to patients with severe left ventricular systolic dysfunction (FE < 30%), symptomatic (NYHA class greater than IIa), reduced functional capacity (assessed by cardiopulmonary test or six minute walking test) recent hospitalisation (first diagnosis of heart failure or exacerbation of heart failure with congestive phenotype or with clinical signs of low flow rate or sustained ventricular arrhythmias) and will be referred by the Foundation’s internal or external physicians with a view to undertaking a course of close clinical and instrumental follow-up and with the plan to be promptly referred to the transplant/left ventricular assist pathway, if possible.
The discharge of patients with advanced HF from hospitals is currently considered a “difficult discharge”; in this regard, our project provides for an ad hoc discharge with the presence of the ward doctor, the dedicated nurse and the caregiver to better illustrate the clinical picture that emerged during hospitalisation and build the patient’s subsequent diagnostic-therapeutic pathway; in the pre-discharge phase it is essential to establish a continuity relationship with the treating doctor and, where necessary, with the local nursing services.
At the advanced HF outpatient visit, all patients will undergo a comprehensive assessment (with an integrated approach of the cardiologist specialist, dedicated nurse, physiotherapist) carried out on the day of first access. Based on the results of the initial assessment, any further instrumental investigations will then be scheduled, any need for hospitalisation will be indicated and the next clinical and instrumental follow-up will be planned.
Overall plan
Outpatient frequency: once every 2 weeks.
From 8:30 am, the three patients will undergo, at 30-minute intervals, the joint nurse-physiotherapist assessment (specified below); then the first cardiological visits will be carried out from 10:00 am to 1:00 pm in the presence of thecaregiver.
At the end of each first visit, an interview will be held between the patient, the caregiver and the multidisciplinary team with the issuance of illustrated information brochures. At the first visits of patients referred by other facilities or by other FTGM clinics, the following questionnaires will be carried out: Kansas City Cardiomyopathy Questionnarie (KCCQ) for the patient, Zarit Burden Interview (ZBI) for the caregiver (repeated after 1 month and then every 6 months). For patients who have already been admitted to our hospital, a service for completing the questionnaires (sent by email or SMS) is already active at discharge. Here again, this is re-assessed at 1 month and then every 6 months.
From 1:15 pm to 3:30 pm, two cardiological check-ups will be carried out, with the possibility of activating the multidisciplinary evaluation on a case-by-case basis.
1. Initial diagnostic assessment (first visit)
From 08:30 am to 10:00 am (dedicated nurse-physiotherapist)
- assessment of vital signs (BP, HR, SpO2) and body weight
- blood tests (blood count, creatinine, electrolytes, liver function, coagulation, HS troponin T, NT-proBNP, sST2, LDH, AST, ALT, gammaGT, total bilirubin)
- baseline electrocardiogram or PM check if necessary (poss. shock of the device)
- recovery of remote PM/ICD monitoring data (for patients who have one)
- in patients with an LVAD, perform driveline dressing and check the alarms
- nursing counselling: lifestyle, adherence to dietary and behavioural rules, compliance with therapy, critical issues in patient management, patient-caregiver relationship
- functional assessment performed by the physiotherapist.
On a case-by-case basis, any visits with the aforementioned specialists will be planned at facilities outside the foundation.
In order to establish the appropriate timing of the cardiological follow-up, we proposed the creation of a dedicated e-mail (scompenso@ftgm.it) and the initiation of serial telephone follow-up by dedicated nurses, also with the aim of providing a system of direct communication between the patient and the advanced outpatient clinic. This follow-up will take place once a month (30 days after outpatient visits or 30 days after hospital discharge, possibly modified on a case-by-case basis).
2. Initial diagnostic assessment (subsequent check-ups)
caregiver will be decided on a case-by-case basis.
The check-up visit includes
- assessment of vital signs (BP, HR, SpO2) and body weight
- baseline electrocardiogram or PM check if necessary (poss. shock of the device)
- in patients with an LVAD, perform driveline dressing and check the alarms
- check-up echocardiogram
In the event of clinical/instrumental worsening, hospital admission will be planned to perform a course of intravenous diuretic therapy, possible treatment with inodilators, the need for a right catheterisation, the initiation of the pathway for eligibility for implantation of a left ventricular assist device or re-evaluation at the Transplant Centre. In patients with a LVAD who experience clinical worsening, hospitalisation is recommended to rule out any complications related to the mechanical assist device (pump thrombosis, bleeding, infectious problems, etc.).