Optimizing Heart Failure-Specific Disease Management Programs and Patient Care in Saudi Arabia: A Saudi Heart...

Heart failure (HF) represents a major and growing health burden in Saudi Arabia, with high morbidity, frequent hospitalizations, and substantial system-level costs. Despite advances in guideline-directed medical therapy, gaps in diagnosis, care coordination, and longitudinal management persist. Structured, multidisciplinary heart failure-specific disease management programs (HF-DMPs) have been shown to improve outcomes and healthcare efficiency, yet their implementation remains inconsistent across the Kingdom.

The Saudi Heart Association (SHA) convened a multidisciplinary expert panel to develop a national position statement on HF-DMPs. Recommendations were formulated through structured consensus, informed by a comprehensive review of international guidelines, clinical trials, real-world evidence, and Saudi-specific data.

The SHA recommends a patient-centered, multidisciplinary HF-DMP framework aligned with disease stage and institutional capacity. Core components include structured referral and return-of-care pathways, integration of primary care as longitudinal care owners, optimized use of multidisciplinary teams, and scalable models incorporating virtual care and home-based services. Special populations, including cardio-oncology, pregnancy-associated HF, and cardiomyopathies, are addressed through adaptive multidisciplinary pathways. Performance indicators and quality metrics are proposed to support benchmarking and continuous improvement. Crucially, this framework is designed to synergize with the Kingdom's Model of Care, ensuring that these clinical recommendations also offer a practical tool for the new healthcare system. Implementation of structured, capacity-based HF-DMPs is recommended as a pragmatic and scalable approach to enhance care coordination, optimize resource utilization, and reduce preventable HF morbidity and hospitalization at a national level.