Tiny Jaarsma. Heart failure INTER-PROFESSIONAL TEAM APPROACH TO PATIENTS WITH HEART FAILURE

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1 832 Heart failure INTER-PROFESSIONAL TEAM APPROACH TO PATIENTS WITH HEART FAILURE Tiny Jaarsma Take the online multiple hoie questions assoiated with this artile (see page 846) QUALITY I Heart 2005; 91: doi: /hrt n most developed ountries worldwide, the number of patients with hroni heart failure is growing, with 1 3% of the adult population suffering from this syndrome, rising to about 10% in the very elderly. Beause the inidene of heart failure inreases with age, its prevalene will greatly inrease as our population ages. In the near future a large part of the western population will suffer from heart failure and soiety will be faed with the finanial onsequenes. Heart failure is onsuming about % of the health are budget, with approximately 70% of this being spent on hospitalisation. 1 On average one in five patients is readmitted within 12 months, making heart failure one of the most ommon auses of hospitalisation in people over 65 years of age. In a reent international study omparing three states in the USA and three European ountries, it was found that among a number of diagnoses, inluding diabetes, stroke, or hip frature, the diagnoses of ongestive heart failure and hroni obstrutive pulmonary disease have the highest hospital readmission rates. 2 OF LIFE Not only are readmission rates of heart failure patients higher ompared to hroni medial onditions, but also the quality of life of these patients seems to be highly affeted. Compared with the healthy general population, heart failure patients show a global redution in quality of life in several domains (physial funtioning, role funtioning, and soial funtioning), refleting the severe impat of ongestive heart failure on daily life, even though some patients are in an ambulatory setting. 3 Heart failure redues quality of life more than any other hroni medial ondition (for example, diabetes, arthritis, or hroni lung disease) and patients with multiple onditions have greater derements in funtioning and wellbeing than those with only one ondition. 3 This derease in quality of life is not diretly related to funtional apaity or systoli funtion. 4 Current treatment in heart failure fouses on symptomati improvement, but also on preventing the transition of asymptomati ardia dysfuntion to symptomati heart failure, modulating the progression of heart failure, and reduing mortality. 5 Despite some reent evidene of improved prognosis after a first hospitalisation for heart failure, pharmaologial treatment does not impressively improve the high morbidity and mortality rates assoiated with hroni heart failure. Mortality rates after a first hospitalisation for heart failure are 11 20%, and one year mortality is also high (30 45%). 1 In summary, heart failure is a very ommon, disabling, and ostly disease with a very grim prognosis and poor quality of life. However, a great deal still an be done to improve this situation. In this paper reasons for deterioration of patients and subsequent readmissions will be onsidered, showing that there is still a lot to gain in terms of dereasing readmissions, morbidity, and mortality, and improving the quality of life of a heart failure patient. This paper also illustrates that the management of heart failure is a omplex issue and patient problems are diverse, neessitating a team approah involving different disiplines with differing expertise and skills (fig 1). Correspondene to: Dr Tiny Jaarsma, Department of Cardiology, Thoraxenter, University Hospital Groningen, PO Box , 9700 RB Groningen, The Netherlands; t.jaarsma@ thorax.umg.nl WHY IS AN INTER-PROFESSIONAL TEAM APPROACH NEEDED IN HEART FAILURE? Both from a patient s perspetive and from the point of view of health are providers, there are a number of reasons why several professionals ontribute to optimal and effiient management of heart failure. Health are providers Complexity of diagnosis of heart failure The diagnosis of heart failure relies on linial judgement based on a medial history, physial examination, and appropriate investigations. The linial definition of heart failure is a onstellation of symptoms and signs that onsist of breathlessness, fatigue, and fluid retention resulting from ardia dysfuntion. 5 This definition already gives some indiation as to how

2 Heart failure Management Programme Figure 1 Potential outomes of heart failure management programmes. 833 Patient knowledge and attitude Skills Diagnostis Medial treatment Coordination of are Aess in ase of linial deterioration Self are behaviour/self management Delay treatment seeking behaviour Compliane Symptoms Daily funtion Psyhosoial problems Resoure utilisation Patient satisfation Quality of life Costs Survival omplex the diagnosis of heart failure might be, sine urrently there is no reognised ut-off value of ardia or ventriular dysfuntion or hange in flow, pressure, dimension, or volume that an be used reliably to identify patients with heart failure. The European Soiety of Cardiology guidelines state: a patient to be diagnosed with heart failure should have the following features: symptoms of heart failure, typially breathlessness or fatigue, either at rest or during exertion, or ankle swelling and objetive evidene of ardia dysfuntion at rest. A linial response to treatment direted at heart failure alone is not suffiient for diagnosis, although the patient should generally demonstrate some improvement in symptoms and/or signs in response to those treatments where a relatively fast symptomati improvement ould be antiipated e.g. diureti or nitrate administration. 5 Co-morbidities, age, and medial treatment may obsure a diagnosis of heart failure. General pratitioners (GPs), ardiologists, internists, and geriatriians need to ooperate to establish the diagnosis and underlying aetiology of heart failure. Complexity of heart failure treatment Alongside the omplexity of diagnosing heart failure, treatment of heart failure has also beome inreasingly omplex. Treatment inludes mediations that prolong life, alleviate symptoms, and redue admissions to hospital. 5 Not only should the right mediation be presribed, but adequate doses should be titrated. In uptitrating drugs in the individual patient, dosages that are advised in guidelines should be aimed for instead of titration based on symptomati improvement alone. Uptitrating agents on top of other mediation sometimes an be a time onsuming and preise job, involving several linial deisions. Other omplex deisions in treatment an be related to surgery or devie therapy: implantable ardioverter defibrillators (ICDs), biventriular (multi-site) paing, heart transplantation, or ventriular assist devies. Several professional experts are needed to deide on and administer heart failure treatment. Co-morbidity In most patients, a range of onomitant disorders aompanies heart failure that both ontribute to the ause of the disease (for example, hypertension, ishaemia, diabetes mellitus) and have a key role in its progression and response to treatment. 6 In addition, o-morbid disorders often impliate a medial regimen that inludes mediation for several disorders and several non-pharmaologial treatment aspets (for example, diet and exerise). Co-morbid disorders also enhane the possibility for polypharmay, whih may lead to adverse drug interations (for example, adding spironolatone to a regimen that inludes potassium supplements). Several drugs should be avoided or used with aution when o-presribed with any form of heart failure treatment (table 1). Cardiologist, pharmaists, internists, GPs, heart failure nurses, and dietiians an have a role in hoosing the appropriate regimen for a patient with several diseases.

3 834 Table 1 Drugs to be avoided in heart failure patients 1. Non-steroidal anti-inflammatory drugs (NSAIDS) 2. Class I antiarrhythmi drugs 3. Calium antagonists (verapamil, diltiazem, first generation dihydropyridine derivatives) 4. Triyli antidepressants 5. Cortiosteroids 6. Lithium 7. Illiit drugs (for example, oaine, amphetamines) Patients with heart failure Elderly Although the therapeuti approah to heart failure in the elderly should be prinipally idential to that in younger heart failure patients, treatment should be applied more autiously. Sometimes redued dosages are neessary due to, for example, altered pharmaokineti and pharmaodynami properties of ardiovasular drugs and renal dysfuntion. Changing lifestyle an be more ompliated in elderly patients, and introduing a omplex and hanging mediation regimen an be more diffiult. 7 Changes in nutritional habits in elderly patients an lead to redued alorie/protein intake, possibly resulting in additional ompliations. Physiians, nurses, and other health are professionals need to ombine their efforts and adapt their approah to older, often vulnerable, heart failure patients. Coping with omplex lifestyle hanges Most patients with heart failure get a omplex therapeuti regimen that onsists of mediation, diet and fluid restrition, daily weighing, and reommendations on ativity and rest. The individual patient often has to integrate these lifestyle hanges in an already existing medial regimen related to other o-morbid diseases. Non-ompliane with mediation and other lifestyle reommendations in heart failure patients is reognised as a major potential problem. Non-ompliane an have important onsequenes for individual heart failure patients suh as worsening symptoms, sometimes leading to readmission. 7 Eduation and ounselling by a multidisiplinary team, with speifi team members addressing speifi items, has an important role in improving ompliane. Possible impaired ognitive funtion and/or depression Patients with heart failure an suffer from ognitive dysfuntion and depression, whih will influene eduational strategies and ompliane with the medial regimen. Forgetfulness or lak of interest an have a major ontribution to ompliane with treatment or keeping appointments. These omplex problems need a patient entred and broad Need for inter-professional team approah Health are providers omplexity of diagnosis of heart failure omplexity of heart failure treatment o-morbidities Patients elderly oping with omplex lifestyle hanges possible impaired ognitive funtion and/or depression approah, requiring input from physiians, nurses, and other health are providers. Ignoring the omplexity of heart failure for both health are providers and patients an have onsequenes for patient outomes. 7 Table 2 shows fators related to hospital readmission in heart failure patients. It is generally reognised that a large proportion of heart failure readmissions are preventable. Several studies have onluded that readmission ould have been avoided in 40 59% of patients if there had been better assessments, if treatment would have been optimised, if rehabilitation had been more adequate, if disharge had been more arefully planned, if potential non-ompliane issues and diet had been identified, and if patients had been instruted to seek medial assistane when symptoms our. 1 8 Summarising, health are pratitioners who treat heart failure patients often fae the hallenge of managing multiple onditions requiring multiple mediations and lifestyle hanges in an older, sometimes ognitively and psyhologially affeted patient group. An inter-professional team approah is needed to optimally diagnose, arefully review and presribe treatment, eduate and ounsel patients and families in regard to mediation use and lifestyle hanges, and provide post-disharge follow up. WHAT IS AN OPTIMAL MODEL TO DELIVER INTER- PROFESSIONAL CARE? To date there have been several studies to evaluate the effet of heart failure management programmes designed to improve outomes in patients with heart failure. These programmes all differ in ontent and intensity. Although there are a large number of within-model variations, the majority of programmes an be lassified as either heart failure outpatient lini or home based management programme. In addition, ombinations of these models or new approahes, like telemonitoring, are used in delivering heart failure are. Table 2 Reasons for deterioration of heart failure often leading to readmission Cardia Atrial fibrillation Other supraventriular or ventriular arrhythmias Myoardial ishaemia Appearane of worsening of mitral or triuspid regurgitation Exessive preload redution (diuretis + ACE inhibitors) Non-ardia Infetion Pulmonary embolism Co-presribed drugs Alohol abuse Renal dysfuntion (exessive use of diuretis) Thyroid dysfuntion (for example, amiodarone) Anaemia (hidden bleeding) Inadequate or inappropriate medial treatment Disharge in unstable ondition Adverse effets of presribed treatment. Inadequate knowledge of hroni heart failure and presribed treatment Non-ompliane with presribed treatment Inadequate follow up Problems with aregivers or extended are failities Poor soial support ACE, angiotensin onverting enzyme.

4 Heart failure outpatient lini In a heart failure lini model, are is delivered in an outpatient setting by health are providers with heart failure expertise to patients who attend the lini. In some linis the programme starts while the patient is still in the hospital, but the primary site of are delivery is the outpatient lini. Nurses and ardiologists an have several roles in the heart failure lini and have a responsibility to bridge the gap between the inpatient and outpatient are. Nurses an play an important role in oordinating or failitating are. In other linis nurses have a more independent role in managing and direting are, with primary responsibility for the day-to-day are of patients. For example, in a heart failure lini studied by Strömberg and olleagues, the programme onsisted of eduation aimed at assisting patients to improve their self are regimen, nonpharmaologial treatment, protool led hanges in mediation, psyhosoial support, and availability of nurse ontat in ase of problems. The first heart failure lini visit was sheduled 2 3 weeks after disharge. 9 When patients were stable and well informed they were referred bak to their GP in primary are. Some other heart failure linis will keep the patients on regular follow up, without referring them bak to their GP. Refleting on the advantages and disadvantages of a heart failure lini, one might say that a heart failure lini that is situated in an outpatient setting gives the opportunity to have aess to medial equipment, speialist onsultation, laboratory failities, and patients medial harts. At the same time it is known that an outpatient heart failure lini is often not feasible for elderly and the less mobile patients with moderate to severe, hroni heart failure. Home based management programmes In a home based model, are is delivered primarily in patients homes and sometimes inludes home health failities, instead of delivering the are in a lini or outpatient setting. The health are provider omes in person to the home of the patient, alls the patient on the telephone, or both. For example, in a study in a tertiary referral hospital in Glasgow, patients reeived multiple home visits and the nurses initiated and titrated pharmaotherapy aording to pre-established guidelines. Home based speialist nurses provided omprehensive eduation and ounselling, during an early home visit, and frequent visits and alls. The home based speialist nurse was aessible in ase of problems and failitated ommuniation among health are providers. 10 Other models for home based are may be less intensive but still inlude patient eduation, ounselling, and assessment of the need for mediation adjustments during a home visit. 11 The advantage of home based models is that the health are provider has the opportunity to reah vulnerable and frail patients who might not be able to ome to a heart failure lini. Additionally, are is delivered in the non-threatening environment of the patient s home, allowing realisti assessment of the soial situation and possible barriers to nonompliane. At the same time it should be realised that home visits might be very time onsuming and ineffiient in some areas. Furthermore, aess to speialist onsultation, patient medial reords, or medial equipment might be limited in home based models. Combination of models and integrated are programmes (primary and seondary are) There are several options to ombine omponents from a heart failure lini and a home based programme. Some failities might have the option to deliver both models. Other models try to integrate primary and seondary are. For example, the Aukland heart failure management study used an integrated management approah involving primary and seondary are in patients with heart failure. Patients reeived early linial review, three group eduation sessions, patient diary, and regular follow up alternating between the GP and the heart failure lini. 12 Home telemonitoring Telemonitoring an be defined as home monitoring of patients using speial teleare devies in onjuntion with a teleommuniation system. 13 With tehnologial equipment in the patients homes, data an be olleted on weight, blood pressure, ECG, respiratory rate, transutaneous O 2 saturations, and body temperature. Telemonitoring an either be used alone or as part of a multidisiplinary approah. Initial studies have suggested that telemonitoring may redue hospitalisations and readmission rates in patients with heart failure, although more evidene of effiay is required. 13 To date, there are no data available that ompare the relative ost effetiveness of a lini versus home based model of are, or address different strategies. Similarly, there are no studies desribing patient preferenes in this regard. At the same time it is important to note that suh programmes are probably most effetive when both medial treatment, aording to offiial guidelines, and disharge planning is applied in an optimal manner. WHO SHOULD BE INVOLVED? Heart failure teams an omprise several members depending on the goals of are, the population served, and available resoures (finanes, personnel, and expertise). Professionals who an have a role in the omprehensive treatment and are of heart failure patients are: GP, ardiologist, heart failure nurse, home are, internist, dietiian, pharmaist, soial worker, psyhologist, physial therapist, and geriatriian. Depending on the loal health are system, it is important to determine whih health are provider is the most appropriate to partiipate in various omponents (table 3). Table 3 Components of multidisiplinary are Appropriate diagnosis assess severity of symptoms determine aetiology Optimal medial management Intense eduation and ounselling Disharge planning Vigilant follow up Attention to behavioural strategies Address barriers to ompliane Early attention to signs and symptoms (for example, daily weighing, telemonitoring) Flexible diureti regimen Inreased aess to health are providers Exerise programme 835

5 836 Table 4 List of subjets to disuss with a heart failure patient and his or her family General advie Explanation of heart failure and why symptoms our Causes of heart failure How to reognise symptoms What to do if symptoms our Self weighing Rationale of treatments Importane of adhering to pharmaologial and non-pharmaologial presriptions Refrain from smoking Prognosis Advaned diretives Drug ounselling Nature of eah drug, dosing and time of administration Side effets and adverse affets Signs of intoxiation What to do in ase of skipped doses Compliane strategies Ativity, exerise, rest Work, leisure ativities and travel Rest Energy onserving suggestions Daily physial ativity Sexual ativity Rehabilitation: exerise programme Compliane strategies Vainations Symptom assessment and management Expeted symptoms versus symptoms of worsening heart failure Self monitoring of daily weights Ations in ase of inreased symptoms Dealing with psyhologial symptoms Self management (for example, diuretis) Dietary and soial habits Control sodium intake when neessary Avoid exessive fluids in severe heart failure Avoid exessive alohol intake Smoking essation Compliane strategies Patients should be diagnosed and treated aording to the available guidelines and should be adequately eduated (table 4). The ore of the team in a heart failure management programme most often omprises a ardiologist and a heart failure nurse. Together they are responsible for the proper diagnosis, treatment, and are of heart failure patients. The heart failure nurse has a major role in the eduation and ounselling of patients and family, and helping patients when they present signs or symptoms of deterioration. In addition, heart failure nurses an help the patient to learn to live with the onsequenes of heart failure, whih means: omply with a regimen onerning mediation, diet and exerise, monitor symptoms, seek assistane when symptoms our, and take relevant ations in ase of exaerbation for example, to alert a health are provider or adjust their diureti dose aordingly. There has been a development in the role of the heart failure nurse, leading to more independent funtion in regard to protool driven drug titration, referrals, and post-disharge follow up review of patients. However, in most health are systems, ultimately the ardiologist has the final responsibility for the medial management, ompleteness of investigation, and planning and initiation of the therapeuti strategy. GPs (primary are physiians) are involved in the patient s ourse of heart failure at several stages. This starts with the important role in the prevention of heart failure through the early identifiation of potential aetiologial fators and the aggressive management of identified risk fators. Additionally, the GP has a ruial role in the initial diagnosis, implementation of evidene based treatment, and subsequent follow up arrangement, where all ativities are aimed at maximising prognosis. 14 It is known that patients with heart failure visit their GP often with heart failure as the most ommon reason for onsultation. 12 Independent of the model of the heart failure programme, a lose ooperation between primary are and the hospital team should be established. Dietiians an help to evaluate dietary intake, formulate tailored advie in regard to speifi patient needs (for example, ombine a heart failure diet with a diabetes diet), and help patients to improve ompliane with a presribed nutrition reommendation. Another important aspet in dietary ounselling is the importane of a healthy body weight. Being either overweight or underweight are serious onerns in patients with heart failure. Weight redution in obese heart failure patients an be a omplex issue needing speialised guidane by a dietiian. On the other hand, preventing and treating ardia ahexia may need more attention. Two studies evaluating the effets of a multidisiplinary approah to heart failure expliitly reported on the role of the dietiian However, the role of the dietiian is often poorly desribed ( provision of dietary instrutions ). Other minor publiations only fous on the individual role of the dietiian in heart failure, showing that eduation by a dietiian improves knowledge and awareness and dereases sodium and fluid intake of heart failure patients. Physial therapists an advise the patient with heart failure on reonditioning and training, and also give pratial advie on energy onservation. Patients that are seen at the heart failure lini have often been de-onditioned by, for example, prolonged bed rest or repeated hospitalisations. Others have been inative beause of fear of inreasing symptoms or fear of exertion. These patients possibly an benefit most from exerise programmes, either in a ardia rehabilitation entre, in a hospital based exerise programme, or in a home exerise programme. Low intensity home walking exerise programmes for patients with stable, moderate heart failure are safe, well aepted, and effetive in improving funtional status (submaximal exerise apaity) and global pereption of symptoms. Pharmaists already have a well established role in heking on interations and possible treatment of adverse events when new drugs are initiated. Additional interventions by pharmaists an inlude providing advie to physiians in hoosing the appropriate drug regimen and dosages, and on improving ompliane and the patient s knowledge of heart failure. Studies show that patient eduation and goal setting by pharmaists an inrease patient knowledge, the appropriateness of mediations taken by patients, and patient ompliane. 17 Psyhologists and/or soial workers an help patients to ope with the effets of heart failure in their daily life.

6 Psyhologists an also help dotors and heart failure nurses speifially to look for and identify symptoms of depression in patients with heart failure at an early stage. In the omplex management of heart failure patients, one an imagine that heart failure linis hoose to inlude other health are professionals in the team. For example, when working with a pre-heart transplant population, lose ollaboration with transplant oordinators is quite obvious. Working with a hroni and elderly population, some heart failure linis onsider involving geriatriians. Eah heart failure team lini should establish whih health are provider will be the obvious person for addressing the speifi patient problem. IS AN INTER-PROFESSIONAL TEAM APPROACH EFFECTIVE? A reent meta-analysis by MAllister and olleagues 18 reported that multidisiplinary management strategies for patients with heart failure are assoiated with a 27% redution in heart failure hospitalisation rates and a 43% redution in the total number of heart failure hospitalisations. Those strategies that inorporate speialised follow up by a multidisiplinary team also redue all ause mortality by approximately a quarter and all ause hospitalisations by a fifth. In this meta-analysis, 29 studies were inluded that speifially addressed several models of multidisiplinary management. The authors disuss the elements that should be inluded in the multidisiplinary management of heart failure patients: the involvement of speially trained heart failure nurses, patient eduation, and ready aess to liniians trained in heart failure. Although a wide variety of multidisiplinary strategies exist to manage patients with heart failure, the most optimal model or intensity annot be determined. Available evidene does not support the assumption of inremental effiay with more intensive post-disharge intervention. Almost all studies that were evaluated for effetiveness used a multidisiplinary team approah, with teams varying from a ardiologist and a speialised heart failure nurse to a more extended multidisiplinary team aring for heart failure patients. 18 An example of an intensive omprehensive disharge programme is desribed by Rih and olleagues, 15 who reported that a multidisiplinary intervention had benefiial effets as regards rates of hospital readmission, quality of life, and ost of are within 90 days of disharge among high risk hroni heart failure patients. The multidisiplinary team onsisted of omprehensive eduation of the patient and family by a heart failure nurse, provision of dietary instrutions by a registered dietiian, and appropriate postdisharge are by soial servies. A geriatri ardiologist reviewed eah patient s mediations and gave speifi reommendations to simplify and onsolidate the regimens by minimising both the number of mediations and the dosing. However, the final hoie of mediation was left to the disretion of the patient s primary physiian. Home are servies were supplemented by individual home visits and telephone ontat. 15 More reently MDonald and olleagues 16 in Ireland also reported on the effets of a multidisiplinary heart failure lini. In this study the intrinsi benefit of multidisiplinary are in the setting of protool driven optimal medial management of heart failure was demonstrated. Team members were the ardiology servie, the heart failure nurse, and a speialist dietiian who onsulted patients during the index admission. CONCLUSION AND OUTLOOK An organised system of speialist heart failure are improves outomes, inluding quality of life, the frequeny and duration of follow up, and survival in patients with heart failure. A multidisiplinary team approah involving several professionals with their own expertise is important in attaining an optimal effet. Physiians, nurses, and other health are professionals are key to ensuring the delivery of evidene based are. Considering the aging population, an inreasing number of heart failure patients will need speialised treatment, are, and guidane in the omplex issues of heart failure and omorbidities. As a onsequene, the role of individual health are providers is likely to hange in the future for example, more patients will be referred to a heart failure management programme and more patients in a stable ondition will be referred bak to their GP or primary are provider. In future, the role of the heart failure nurse probably will be more independent from the physiian for example, in regard to optimisation of medial treatment and independent patient follow up. However, one should keep in mind that appropriate training of the health are professionals involved will always be important. To deliver ost effetive are, future treatment and follow up strategies an be expeted to beome more tailored to the individual patient. Criteria will be developed that will give diretion as to what are is needed and whih interventions are most effetive for a ertain group of patients (for example, seleting high and low risk patients). Trials that ompare the effets of different models are underway. 19 Reently the use of B type natriureti peptide (BNP) has been reognised as being inreasingly important in the diagnosis of heart failure and helpful in guiding treatment and monitoring the ourse of heart failure, partiularly in alerting liniians to deompensation. 20 Taking this onept further, it an be hypothesised that BNP measurement may also prove a useful addition to linial assessment in situations where risk stratifiation is required for example, to determine whih patients may need additional follow up. BNP onentrations might help to determine whih patients might be andidates for early follow up and perhaps home nursing visits. Markers of linial (in)stability, psyhosoial risk fators, and issues related to patient mobility might be important indiators to determine whih inter-professional servie might be most effetive for whih patient. In the meantime, health are providers should realise that a multidisiplinary approah annot be ignored in the provision of optimal treatment and are for heart failure patients. REFERENCES 1 MMurray JJ, Stewart S. The burden of heart failure. Eur Heart J 2003;5(suppl): Westert GP, Lagoe RJ, Keskimaki I, et al. An international study of hospital readmissions and related utilization in Europe and the USA. Health Poliy 2002;61: Stewart AL, Greenfield S, Hays RD, et al. Funtional status and well-being of patients with hroni onditions: results from the medial outomes study. JAMA 1989;262: Study omparing funtional status and wellbeing between nine ommon hroni medial onditions of 9385 patients in the USA

7 838 4 Jaarsma T, Halfens R, Huijer-Abu Saad H, et al. Quality of life in older patients with systoli and diastoli heart failure. Eur J Heart Fail 1999;1: Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of hroni heart failure. Eur Heart J 2001;22: Krum H, Gilbert RE. Demographis and onomitant disorders in heart failure. Lanet 2003;362: Wal van der MHL, Jaarsma T, Veldhuisen van DJ. Non-ompliane in patients with heart failure; how an we manage it? Eur J Heart Fail 2005;7:81 6. Literature review on the degree and the onsequenes of nonompliane in heart failure, and possible interventions. 8 Mosterd A, Hoes AW. Reduing hospitalizations for heart failure. Eur Heart J 2002;23: Stromberg A, Martensson J, Fridlund B, et al. Nurse-led heart failure linis improve survival and self are behavior in patients with heart failure. Results from a prospetive, randomized trial. Eur Heart J 2003;24: First study to find signifiant effets on mortality of a heart failure lini. 10 Blue L, Strong E, Murdoh DR, et al. Improving long-term outome with speialist nurse intervention in heart failure: a randomized trial. BMJ 2002;323: First randomised study to examine a programme of are where speialised nurses, in addition to providing eduation and ounselling, initiated and titrated pharmaotherapy during home visits. 11 Stewart S, Horowitz JD. Home-based intervention in ongestive heart failure: long-term impliations on readmission and survival. Cirulation 2002;105: This study reports long term follow up of patients after a multidisiplinary home based intervention with a post-disharge home visit at 7 14 days. 12 Doughty RN, Wright SP, Walsh HJ, et al. Randomised, ontrolled trial of integrated heart failure management: the Aukland heart failure management study. Eur Heart J 2002;23: In this study, integration between primary and seondary are was attempted. Authors also desribe frequent visits to the GP. 13 Louis AA, Turner T, Gretton M, et al. A systemati review of telemonitoring for the management of heart failure. Eur J Heart Fail 2003;5: Hobbs FD. Primary are physiians: hampions of or an impediment to optimal are of the patient with heart failure? Eur J Heart Fail 1999;1: Rih MW, Bekham V, Wittenberg C, et al. A multidisiplinary intervention to prevent readmission of elderly patients with ongestive heart failure. N Engl J Med 1995;333: First properly powered randomised study of a multidisiplinary intervention in heart failure. 16 MDonald K, Ledwidge M, Cahill J, et al. Elimination of early rehospitalization in a randomized, ontrolled trial of multidisiplinary are in a high-risk, elderly heart failure population: the potential ontributions of speialist are, linial stability and optimal ACE-inhibitor dose at disharge. Eur J Heart Fail 2001;3: Irish study reporting a very high suess of a multidisiplinary intervention. 17 Gattis WA, Hasselblad V, Whellan DJ, et al. Redution in heart failure events by the addition of a linial pharmaist to the heart failure management team: results of the pharmaist in heart failure assessment reommendation and monitoring (PHARM) study. Arh Intern Med 1999;59: Randomised study desribing the addition of a linial pharmaist to the heart failure management team. 18 MAlister FA, Stewart S, Ferrua S, et al. Multidisiplinary strategies for the management of heart failure patients at high risk for admission. A systemati review of randomized trials. J Am Coll Cardiol 2004;44: Meta-analysis of 29 studies that speifially addressed multidisiplinary strategies for the management of heart failure patients. 19 Jaarsma T, Van Der Wal MH, Hogenhuis J, et al. Design and methodology of the COACH study: a multienter randomised oordinating study evaluating outomes of advising and ounselling in heart failure. Eur J Heart Fail 2004;6: Cowie MR, Jourdain P, Maisel A, et al. Clinial appliations of B-type natriureti peptide (BNP) testing. Eur Heart J 2003;24: Summarises the urrent evidene on BNP and provides guidane for pratising liniians.