QEH’s comprehensive heart failure programme reduces mortality and hospitalization

Heart failure (HF) has a 5-year mortality rate of >50 percent. Delays in diagnosis and initiation and uptitration of guideline-directed medical therapy (GDMT) remain significant gaps in HF management. In an interview with MIMS Doctor, Consultant Cardiologist Dr Michael Lee, Associate Consultant Cardiologist Dr Esmond Fong, and Cardiac Nurse Consultant Ms Cecilia Chan from the Queen Elizabeth Hospital (QEH) shared a comprehensive inpatient and outpatient HF management programme run by a multidisciplinary team (MDT), which successfully improved hospitalization for HF (HHF)–free survival, reduced length of hospital stay, and improved other functional outcomes in local patients.

HF: More “malignant” than cancer
HF is prevalent in Hong Kong, affecting 1.2 percent of the population or approxi­mately 90,000 people. [Korean J Trans­plant 2022;36:267-277]

“HF places a significant strain on our public healthcare system as approximately 10 percent of patients admitted daily have HF,” said Fong. Among patients aged ≥85 years, the annual rate of hospitalization for new-onset HF in Hong Kong was as high as 9.07 per 1,000 population. HF is one of the five leading causes of hospitalization in the Hospital Authority (HA) and is the pri­mary cause of hospital admissions and re­admissions at QEH. [HA Board Paper No. 355; J Card Fail 2016;22:600-608]

“After initial HHF, the 5-year mortality rate is alarmingly high at 54 percent, which is even higher than that in cancer patients,” commented Lee.

Current service gaps in HA
HF diagnosis is often delayed be­cause patients are typically admitted for shortness of breath (SOB), which is a nonspecific symptom that may also indicate noncardiac issues. [Curr Heart Fail Rep 2022;19:247-253; ESC Heart Fail 2018;6:16-26]

“In the past, we did not have reli­able biomarkers for HF, and access to echocardiography for diagnosis and monitoring in the inpatient setting was limited,” said Lee and Chan. “In most hospitals, the waiting time for an echocardiography is over a year [>68 weeks].” [HA Board Paper No. 355]

“Additionally, acute HF is primarily treated by physicians in general med­ical wards, with only a small fraction being managed by cardiologists. This results in suboptimal initiation and up­titration of GDMT,” said Fong and Lee.

QEH’s comprehensive HF programme
The multinational, open-label, ran­domized, parallel-group STRONG-HF trial (n=1,078) showed that high-intensity care consisting of rapid uptitration of GDMT and close follow-up after an acute HF admission reduced all-cause death or HF readmission at 180 days vs usual care. [Lancet 2022;400:1938-1952]

“In October 2022, QEH launched a comprehensive HF programme that adopts an intensive treatment strategy similar to that in the STRONG-HF trial, focusing on early diagnosis and rapid initiation and uptitration of GDMT to im­prove patient outcomes,” stated Chan and Fong.

The programme has two parts, of­fering multidisciplinary HF management for targeted patients from acute (inpa­tient) to chronic (outpatient) phases. (Figure 1) [HA Board Paper No. 355]

“What sets our programme apart is the inpatient component that most hospitals do not offer,” pointed out Lee. “We also included patients with more severe HF, including those in New York Heart Association [NYHA] func­tional class IV. In contrast, most other HF programmes only accept patients in NYHA functional classes I and II.” (Figure 1)

NT-proBNP screening
Patients with SOB admitted to QEH’s Accident and Emergency Depart­ment (AED) are tested for N-terminal pro– B-type natriuretic peptide (NT-proBNP) level, a key biomarker for HF diagnosis. (Figure 1) [HA Board Paper No. 355; J Res Med Sci 2011;16:1564-1571]

“Our laboratory generates a daily list of NT-proBNP results, allowing us to identify patients with elevated NT-proBNP levels of ≥125 ng/mL. On av­erage, we identify 40–60 patients with elevated NT-proBNP levels each day,” stated Fong and Lee.

“Cardiac nurses screen and select patients with premorbidity for enrol­ment in our programme,” added Chan.

MDT daily ward rounds
“Enrolled patients are managed by our inpatient HF team, which includes three cardiac nurses and a cardiolo­gist, a pharmacist, a physiotherapist, and an occupational therapist,” said Lee. “Patients are assigned to general medical ward, HF bed, coronary care unit [CCU], or intensive CCU accord­ing to the severity of their condition.” (Figure 1)

“Our cardiologist, cardiac nurses and pharmacist provide daily consul­tations in medical wards for enrolled patients,” said Fong. “During the ward rounds, our cardiologist performs fo­cused cardiac ultrasound [FoCUS] assessment to rapidly evaluate left ventricular ejection fraction and identi­fy any major HF issues. If needed, car­diac nurses will arrange a fast-track full echocardiography and offer inpatient rehabilitation referrals for physiotherapy and occupational therapy.” (Figure 1)

“Our pharmacist reassesses these patients every 2 days, conducts med­ication reconciliation, and titrates the GDMT to the highest possible dose before patients are discharged,” said Fong. (Figure 1)

HF Cardiac Ambulatory Centre
“HF patients can be particularly vul­nerable, having high readmission and mortality rates shortly after discharge. For patients enrolled in our programme, cardiac nurses organize follow-up ap­pointments at our HF Transition Clinic at the Cardiac Ambulatory Centre within 2 weeks postdischarge,” stated Chan. “The follow-up frequency in the Tran­sition Clinic ranges from a few days to 2 weeks, depending on each patient’s condition, which is markedly shorter than the 6–8 months typically required for follow-ups in standard outpatient settings.”

“Cardiac nurses have led the HF Nurse Clinic at Cardiac Ambulatory Centre since 2008. The comprehen­sive HF programme launched in 2022 has expanded their services to include GDMT uptitration according to the pre­set protocol endorsed by cardiologists — an uncommon practice in other HF transition clinics,” pointed out Chan. (Figure 1)