Heart failure disease management works, but will it succeed?

This editorial refers to "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" by J. Gonseth et al. on page 1570 and "Heart failure clinics and outpatient management: review of the evidence and call for quality assurance" by F. Gustafsson and J.M.O. Arnold on page 1596 †.Quality of care is defined as "the degree to which health services… increase the likelihood of desired health outcomes and are consistent with current professional knowledge".1 Despite tremendous advances in our understanding of the pathophysiology of heart failure and the development of efficacious therapies, the quality of care for patients with heart failure is suboptimal. For example, although ACE-inhibitors carry a Class I guideline recommendation for patients with left ventricular systolic dysfunction, less than 70% of eligible patients receive such therapy at the time of discharge from a heart failure hospitalisation.2,3 ACE-inhibitor use is even lower among heart failure outpatients, and rates of use of other indicated therapies such as I²-blockers are lower still.4 In other words, the potential of scientific advances to optimise patient outcomes has not been realized because of the failure to implement these discoveries fully in clinical care.The implementation of 'guideline-based' therapies in clinical practice is challenging because of the complexity of the recommendations for care. For example, in symptomatic patients with ischaemic cardiomyopathy, current guidelines support the use of seven or more medications and consideration of interventions such as coronary revascularization, implantable defibrillators, and biventricular pacemakers.5,6 Heart failure care is also intensive, requiring close monitoring on the part of clinicians (e.g., the initiation and up-titration of I²-blockers) and patient self-management (daily weights, diet modification, titration of diuretics, etc.). Finally, heart failure is a disease of the elderly, … *Correspondence to: John S. Rumsfield, Cardiology/CV Outcomes Research (111B), Denver VA Medical Center, 1055 Clermont Street, Denver, CO 80220, USA. Tel.: +1 303 370 7575; fax: +1 303 370 7580 (E-mail: john.rumsfeld{at}med.va.gov).