Heart failure
Heart failure is a frequent and serious chronic disease that affects more than 1.5 million people in France.
Every year :
- 120,000 new cases are diagnosed
- 165,000 hospitalizations are linked to cardiac decompensation
- 70,000 people die from this disease
50% of patients will be rehospitalized 6 months after leaving hospital for cardiac decompensation. It is necessary to set up an efficient care pathway, involving the patient and the medical and paramedical health professionals in the city as well as in the hospital. The aim is to improve patient follow-up after hospitalization to detect and treat cardiac decompensation early in order to reduce relapses and the number of returns to hospital in emergency conditions.
Care course
1- Diagnosis
Heart failure (HF) occurs when the heart has difficulty pumping enough blood to oxygenate all organs. It can be the consequence of a myocardial infarction, arterial hypertension, arrhythmias (atrial fibrillation) or heart muscle disease (cardiomyopathies) often of genetic origin.
The main symptoms are the onset of abnormal shortness of breath on exertion, weight gain, edema or even unexplained fatigue. In the presence of these symptoms, a medical consultation is necessary in order to make a diagnosis based on the dosage of natriuretic peptides and echocardiography and to begin treatment. This is done most of the time by the general practitioner or by the cardiologist, but if signs of seriousness exist, the diagnosis will be made in the emergency room. Early management slows the progression of the disease and could prevent the occurrence of serious cardiac decompensation.
2- The initial assessment
Several examinations are carried out to assess the severity of Heart Failure (HF), to find its cause and possible associated pathologies:
- Physical examination
- Complementary examination such as cardiac ultrasound, chest X-ray, blood test for biological assessment and assay of cardiac biomarkers (NtproBNP)
- Search for comorbidities
This phase will also make it possible to determine with the patient:
- The impact of HF on the activities of his daily life
- Problems posed by associated comorbidities
- Their expectations, their motivations for change
- His ability to modulate his way of life
- Possible barriers to effective care (psychological and social)
- For elderly patients (> 75 years old): an additional assessment of their cognitive functions, their autonomy and their nutritional status may be necessary
The various results will make it possible to orient the treatment and to specify the methods of monitoring the patient.
3- Treatment and follow-up after the initial assessment, role of therapeutic education
Treatments aim to prevent episodes of decompensation, reduce the number and duration of hospitalizations and slow the progression of the disease by reducing the risk of mortality. Another objective of treatment is to improve the quality of life of patients by relieving their symptoms (shortness of breath, fatigue, oedema, etc.) in order to allow them to live better on a daily basis.
The management of IC is therefore global and the treatment always includes:
- Non-pharmacological treatment: new eating habits (low sodium diet) and the practice of regular physical activity
- Pharmacological treatment
- And in some cases an electrical device: bi-ventricular pacemaker, implantable defibrillator…
Doctors from the Pitié-Salpêtrière cardiology institute and the ICAN have set up since 2006, with nurses and dieticians from the department, a therapeutic education program (ETP) in heart failure. It is an integral part of the patient’s care pathway. Offered to the patient shortly after the diagnosis, the program includes several group workshops (programme 10/326 accredited by the ARS). It improves the follow-up of patients: therapeutic education aims to help the patient (and his entourage) to acquire skills allowing him to manage his disease, to tame it and to prevent avoidable complications. The cardiology department and the IHU-ICAN have set up 6 workshops, lasting 1 hour each, to address various essential themes: the disease and its symptoms, nutrition and the practice of physical activity. . In practice, the patient comes for 2 days on an outpatient basis, 1 month apart.
- On the 1st day, an educational diagnosis is made by the team with the patient in order to know his level of knowledge about his illness but also his expectations regarding the program offered to him in TPE. Once this self-test has been carried out, a multidisciplinary medical team proposes and organizes with the patient a therapeutic education program according to the nature of his skills, depending on the stage and the evolution of his disease. The day continues for the patient with the participation in 3 workshops: on the pathology – its symptoms and the signs that should lead him to consult when they occur – the controlled salt diet and breathing during physical effort in order to practice regular physical activity in a comfortable way.
- 1 month later, a second day of therapeutic education is planned with the patient in order to complete and finish this program by participating in the last workshops concerning the drugs, the diet and its compatibility with social life, as well as a more in-depth management of breath during effort. This second day is an opportunity to develop a personal project for the patient with the therapeutic education team.
This program has been enriched over the years to adapt to new medical and paramedical practices and patient behavior. The integration of digital tools from hospitalization to make more patients aware of the risks associated with their disease and of solutions to better understand heart failure is currently being assessed.
4- Returning home is a key step in the progression of the disease
In the event of hospitalization, the course of care must make it possible to prepare for the patient’s discharge from the hospital to ensure the continuity of care in the city under the best conditions, especially in the event of discovery of the disease. The majority of patients who return home after hospitalization often feel left to their own devices, insufficiently informed about their disease and about what to do in the event of further deterioration. At present, a hospitalization report is given to the patient when he leaves hospital and is sent to his referring doctors. For practical issues (availability, waiting time, misunderstanding), the majority of patients with heart failure can only see their GP or cardiologist about 6 weeks after discharge. This delay makes post-hospitalization monitoring and optimization of drug treatments difficult, the dosages of which must be increased gradually.
To improve the follow-up of patients after discharge from hospital, remote follow-up programs have been set up by the health insurance. There is the Home Return Assistance Program (PRADO): Several home visits by a nurse upon return home for follow-up and therapeutic education as well as the organization of appointments with the attending physician and cardiologist are managed by dedicated staff prior to the patient’s discharge and a follow-up log is given to him. Another remote monitoring option which can be complementary to PRADO is the telemonitoring of heart failure developed within the framework of the ETAPES program (Telemedicine experimentation for the improvement of health pathways). Thanks to a tablet and a connected scale which are delivered to him at home, the patient transmits his symptoms and his weight to a platform which filters the alerts and retransmits the relevant alerts to the TV center monitoring in this case the cardiology department of the saltpetre pity. This tele-monitoring, which already existed for patients equipped with defibrillators or pacemakers, makes it possible to better monitor patients and treat symptoms as soon as they appear by adapting treatment early when necessary in order to reduce the number of re-hospitalizations and going to the emergency room. After a phase of experimentation, the social security financing bill brought remote monitoring into common law.
These new telemonitoring techniques and the importance of the possibility of early consultations to better monitor the patient with heart failure and optimize their treatments have reinforced the need for teamwork. In the Pitié Salpêtrière cardiology department, the nurses (some of whom are in cooperation protocol) manage the alerts from the remote monitoring service on a daily basis in collaboration with the patients’ referring doctors. The nurse under cooperation protocol also performs heart failure treatment titration consultations, thus allowing the patient to be seen more regularly.
The course of care for patients with heart failure has therefore evolved in recent years. He was enriched by always trying to leave the patient at the center of his care. Within this course, communication between the various professionals who take charge of it is essential and must however constantly be improved to gain in fluidity. The new connected tools will no doubt be able to contribute to this.
