Hospital-to-community care pathways for patients with heart failure, an inter-society consensus document.

Area of Science:

• Cardiology
• Public Health
• Healthcare Management

Background:

• Heart failure (HF) is a growing global health burden with significant morbidity and mortality.
• Current management strategies require optimization for improved patient outcomes and resource allocation.
• A comprehensive, multidisciplinary approach is essential for effective HF care across care settings.

Purpose of the Study:

• To outline an integrated model for heart failure care in Italy.
• To enhance patient outcomes and resource efficiency in HF management.
• To provide a framework for coordinating hospital and community-based care.

Main Methods:

• Clinical evaluation, ECG, echocardiography, biomarkers, and advanced imaging for diagnosis and phenotyping.
• Guideline-directed medical therapy (SGLT2 inhibitors, ARNIs, beta-blockers, MRAs) as cornerstone treatment.
• Integration of device therapy, cardiac rehabilitation, iron supplementation, telemedicine, and multidisciplinary HF clinics.

Main Results:

• The proposed model emphasizes early detection of deterioration through telemedicine and remote monitoring.
• Multidisciplinary HF clinics facilitate coordinated care, including pharmacological management, rehabilitation, and patient education.
• Structured training and patient empowerment programs enhance adherence and self-management.

Conclusions:

• An integrated model of hospital, community, and digital health resources improves HF patient survival and quality of life.
• This approach effectively reduces hospitalizations and enhances resource utilization.
• Continuous professional training and patient empowerment are key to sustainable and effective HF care.