In Hong Kong, heart failure (HF) is a leading cause of hospitalization with a high readmission rate. Improved HF management models are needed to ensure continuous patient monitoring and rapid uptitration of guideline-directed medical therapy (GDMT). In an interview with MIMS Doctor, Dr Shun-Hei Wong, Specialist in Cardiology at Tseung Kwan O Hospital (TKOH), shared details of TKOH’s new HF management programme, which has notably reduced readmissions and improved functional capacity and other outcomes in patients with acute HF.
Lessons from STRONG-HF and TKOH’s audits
According to a US study of hospitalizations for HF, the rate of readmissions within 30 days of discharge was 18.2 percent between 2010 and 2017, which highlighted gaps in traditional management models. [Circ Heart Fail 2021;14:e008335] The subsequent multinational STRONG-HF trial demonstrated that rapid GDMT uptitration combined with close follow-up after an acute HF admission significantly reduced the risk of all-cause death or HF readmission at 180 days vs usual care (adjusted risk difference, 8.1 percent; p=0.0021; risk ratio, 0.66; 95 percent confidence interval, 0.50–0.86). [Lancet 2022;400:1938-1952]
“Our 2023 audit at TKOH found that >50 percent of patients lacked an echocardiogram within 1 year of an acute HF event, hindering diagnosis and management,” shared Wong. “Postdischarge gaps of several months were common before outpatient follow-up, indicating interrupted care. The audit also revealed suboptimal GDMT use. Sodium-glucose cotransporter-2 inhibitors [SGLT2i] were used in <50 percent of eligible patients, while the other three pillars of GDMT were used in <80 percent, and only 30 percent completed uptitration during follow-up.”
TKOH’s acute HF programme
“STRONG-HF, along with the wider availability of N-terminal pro–B-type natriuretic peptide [NT-proBNP; a crucial biomarker for HF diagnosis and treatment response monitoring] testing across all acute care hospitals in 2024, provided us with an opportunity to improve our protocol and close the care gaps,” explained Wong.
“In January 2025, TKOH launched a new programme that features a hybrid model combining assessments at integrated clinic and teleconsultation services,” said Wong. “To date, we have enrolled about 100 patients from both inpatient and outpatient units.”
Integrated clinic & teleconsultation
“Once decongested and stabilized, patients are started on GDMT. At the integrated clinic, cardiologists perform comprehensive assessment and an echocardiography to evaluate left ventricular ejection fraction [LVEF] and identify HF aetiology,” said Wong. “Physiotherapists conduct a 6‑minute walk test [6MWT]. Patients also complete the Minnesota Living with Heart Failure Questionnaire [MLHFQ] with the help of nurses.”
“About 1–3 teleconsultations are provided over the next 8 weeks, aiming to uptitrate GDMT to individual maximum tolerated doses. Patients are required to enter blood pressure [BP], pulse and weight into the HA Go app daily. This enables patient monitoring, guides drug titration, and informs us if in-person blood tests are required,” stated Wong. “After the teleconsultation period, patients return to the integrated clinic twice for reassessment at weeks 12 and 24.”
“This hybrid model utilizes remote capabilities of teleconsultations, thus reducing manpower requirement,” added Wong.
Promising outcomes
“Programme data from Q1–Q2 of 2025 indicate improvements across all five measured outcomes vs baseline,” reported Wong. These include:
Higher GDMT utilization
“After the launch of this programme, use of all pillars of GDMT reached 100 percent, except in patients with contraindications. Full uptitration was achieved through teleconsultation, which represents a substantial improvement vs the 2023 audit,” said Wong.
Why is GDMT important?
As outlined in the 2024 American College of Cardiology (ACC) expert consensus, each episode of worsening HF may signal a fundamental change in patients’ HF trajectory. Patients admitted with HF have an up to 30 percent risk of death within 1 year. Initiating GDMT early during hospitalization and ongoing optimization of outpatient care are key to support a more favourable postdischarge trajectory, as reinforced by encouraging results from TKOH’s HF programme. [J Am Coll Cardiol 2024;84:1241-1267]
“All four pillars of GDMT are considered safe and should be initiated simultaneously,” said Wong. “For some pillars that may lower BP, careful titration is required to avoid hypotension.”
SGLT2i’s role in GDMT
With proven efficacy across a wide spectrum of patients, SGLT2i play a crucial role in the standard of care for HF. While the other three pillars of GDMT require titration, SGLT2i are given in fixed doses. In addition, unlike neurohormonal inhibitors, SGLT2i have minimal impact on BP and kidney function. Thus, SGLT2i can be started any time after admission in haemodynamically stable patients with estimated glomerular filtration rate ≥20 (empagliflozin only) or 30 mL/min/1.73 m2 (dapagliflozin). (Figure) [J Am Coll Cardiol 2024;84:1241-1267; Nat Med 2022;28:568-574; J Am Coll Cardiol 2024;83:1295-1306]
While all SGLT2i are well tolerated in patients hospitalized for acute HF, empagliflozin is the only SGLT2i that met the primary endpoint in its trial on stabilized acute HF. In the double-blind EMPULSE trial, a higher proportion of patients on empagliflozin vs placebo had clinical benefit at 90 days (win ratio, 1.36; p=0.0054). Consistent clinical benefit was observed across patients with acute de novo or decompensated chronic HF, irrespective of ejection fraction or diabetes status. [J Am Coll Cardiol 2024;83:1295-1306; Nat Med 2022;28:568-574]
