1. IS IT POSSIBLE TO REACH « OPTIMAL THERAPY » IN A SPECIALIZED HEART FAILURE CLINIC? Le Boyer A., Gurné O. Cardiologie Cliniques Universitaires St Luc – UCL Bruxelles PRACTICAL REALISATION AND ADVANTAGE OF HAVING A HEART FAILURE CLINIC IN BELGIUM

2. HEART FAILURE CLINIC GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF CHRONIC HEART FAILURE - ESC 2005 An organized system of specialist heart failure care - improves symptoms and reduces hospitalizations Class of recommandation I, Level of evidence A - improves mortality Class of recommandation IIA, Level of evidence B

3. GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF CHRONIC HEART FAILURE - ESC 2005 Various models have been tested (heart failure clinics, nurse-led home visits,and/or telephone follow-up, multidisciplinary care, extended home care services and telemonitoring,…) It is not clear which model is superior It is likely that the optimal model will depend on local circumstances and resources and whether the model is designed for specific sub-groups of patients

4. 2006 2003 2007 ?

5. THE PROBLEM (S) PAST WAS NOT ALWAYS EASY (PRESENT ?) –Relations between « cardiologists » within the same institution –Relations outside the hospital Cardiologists working in an hospital or outside Cardiologist in the University or in Periphery General practionners and (our) hospital and specialists PROBLEM OF BUDGET –Could be paradoxal « a priori » … but in Belgium… –« un investissement de départ » THESE PROBLEMS ARE EXITING EVERYWHERE

6. THE PROBLEM (S) MIND TO BE CHANGED –DOCTOR = THE ONE who knows (everything) and who does (everything) –patient = the one who is taking the pills without asking any questions –Learn to work in a team –Individualism of the doctors –The patient can – should be an actor of his own health THESE PROBLEMS ARE EXITING EVEYWHERE

7. Heart Failure Clinic - St Luc Hospital Hospital based Nurse led Mainly taking in charge hospitalized patients in cardiology (EF < 35%) –Education –Coordination MD (cardiologist, GP Psychologist Physiotherapist Dietician Nurses of the cardiology unit Home care (AUXAD : logistical support at home) Palliative care –Registry –Follow-up of patients (phone calls ><)

10. Number of CHF patients inclusion extrapolé

11. Number of CHF patients phone calls extrapolé

14. INCLUSION N = 543 patients –Taken from a registry of 1033 patients Ejection fraction < 35%(5 oct 2007) Patients inclusion was made for this survey according to –Follow-up available at 6 months (or death before) in all patients –No Cardiac surgery or PCI during the 6 first months of follow-up Inclusion data obtained at the end of an hospitalization (for the treatment) Comparison between follow-up By a specialized structure n = 163 By another structure (± control group)n = 380

15. FOLLOW-UP specializedheart failure unit Control Group Incl/ 6m163380 12 m13280.1 %230 60.5%

16. ACE TREATMENT % Specialized CHF clinicControl Group P=0.10 P=0.06

17. INH A II TREATMENT % Specialized CHF clinicControl group

18. ACE or AII INHIBITORS TREATMENT % Specialized CHF clinicControl group P=0.02

19. BB TREATMENT % Specialized CHF clinicControl group P=0.001

20. ACE /AII INHIBITORS and BB TREATMENT % Specialized CHF clinicControl group P=0.001

21. SPIRONOLACTONE TREATMENT % Specialized CHF clinicControl group P=0.004 P=0.01

22. ACE /AII INHIBITORS and BB and Spironolactone TREATMENT % Specialized CHF clinicControl group P=0.001

23. Relative ACE INH mean daily dose (in % « max dose » Specialized CHF follow-up Control group

24. Beta Blockers mean daily dose bisoprololcarvedilol bisoprolol carvedilol Specialized CHF clinic Control group

25. Relative BB mean daily dose (in % « max dose » Specialized CHF follow-upControl group

26. % Specialized CHF clinicControl group Combined death or CHF hospitalization events P=0.001 P=0.01

27. CONCLUSION In a relatively unselected population, it is posible to reach a high percentage of patients treated by an ACE Inh or an Inh A II AND a Beta Blocker Higher use of Spironolactone was also achieved The dosage of these compounds can also be simultaneously more increased, even if the target doses described in the large randomised studies performed were not achieved

28. CONCLUSION This approach translate in a better prognosis for these patients It could explained - partially - the results obtained in « Heart Failure Clinics » Others factors, such as education and possibility to maintain a closer contact (telephone, consultation) with the patients, play certainly also an important role

29. ALDACTONE EPLERENONE ACEI ARB