Why is a DMP needed?
How should a DMP for heart failure be organized and how should it function?
Should employ a multidisciplinary approach (e.g. cardiologists, primary care physicians, nurses, pharmacists)
Should target high-risk symptomatic patients
Should include competent and professionally educated staff
Optimized medical and device management
Adequate patient education, with special emphasis on adherence and self-care
Patient involvement in symptom monitoring and flexible diuretic usage
Follow-up after discharge (regular clinic and/or home-based visits; possibly telephone support or remote monitoring)
Increased access to healthcare (through in-person follow-up and by telephone contact; possibly through remote monitoring)
Facilitated access to care during episodes of decompensation
Assessment of (and appropriate intervention in response to) an unexplained increase in weight, nutritional status, functional status, quality of life and laboratory findings
Access to advanced treatment options
Provision of psychosocial support to patients and family and/or caregivers
Definition, etiology and trajectory of HF (including prognosis).
Understand the cause of HF, symptoms and disease trajectory.
Make realistic decisions including decisions about treatment at end-of-life.
Provide oral and written information that takes into account educational grade and health literacy of patients.
Recognize HF disease barriers to communication and provide information at regular time intervals.
Communicate in a sensitive manner information on prognosis at time of diagnosis, during decision making about treatment options, during changes in the clinical condition and on patient request.
Symptom monitoring and self-care
Monitor and recognize change in signs and symptoms.
Know how and when to contact a healthcare professional.
In line with professional advice, know when to self-manage diuretic therapy and fluid intake.
Provide individualized information to support self-management such as:
in the case of increasing dyspnea or edema or a sudden unexpected weight gain of >2 kg in 3 days, patients may increase the diuretic dose and/or alert the healthcare team.
Self-care support aids, such as dosette box when appropriate.
Understand the indications, dosing and side effects of drugs.
Recognize the common side effects and know when to notify a healthcare professional.
Recognize the benefits of taking medication as prescribed.
Provide written and oral information on dosing, effects and side effects.
Implanted devices and percutaneous/surgical interventions
Understand the indications and aims of procedures/implanted devices.
Recognize the common complications and know when to notify a healthcare professional.
Recognize the importance and benefits of procedures/implanted devices.
Provide written and oral information on benefits and side effects.
Provide written and oral information on regular control of device functioning, along with documentation of regular check-up.
Receive immunization against influenza and pneumococcal disease.
Advise on local guidance and immunization practice.
Diet and alcohol
Avoid excessive fluid intake.
Recognize need for altered fluid intake such as:
increase intake during periods of high heat and humidity, nausea/vomiting.
Fluid restriction of 1.5–2 l/day may be considered in patients with severe HF to relieve symptoms and congestion.
Monitor body weight and prevent malnutrition.
Eat healthily, avoid excessive salt intake (>6 g/day) and maintain a healthy body weight.
Abstain from or avoid excessive alcohol intake, especially for alcohol-induced cardiomyopathy.
Individualize information on fluid intake to take into account body weight and periods of high heat and humidity. Adjust advice during periods of acute decompensation and consider altering these restrictions towards end-of-life.
Tailor alcohol advice to etiology of HF, e. g. abstinence in alcoholic cardiomyopathy.
Normal alcohol guidelines apply (2 units per day in men or 1 unit per day in women) where 1 unit is 10 ml of pure alcohol (e. g. 1 glass of wine, 0.3l of beer, 1 measure of spirits).
Smoking and recreational substance use
Stop smoking and usage of recreational substances.
Refer for specialist advice for smoking cessation and drug withdrawal and replacement therapy.
Consider referral for cognitive behavioral theory and psychological support if patient wishes support to stop smoking.
Undertake regular exercise sufficient to provoke mild or moderate breathlessness.
Advice on exercise that recognizes physical and functional limitations, such as frailty, comorbidities.
Referral to exercise program when appropriate.
Travel and leisure
Prepare travel and leisure activities according to physical capacity.
Monitor and adapt fluid intake according to humidity (flights and humid climate).
Be aware of adverse reactions to sun exposure with certain medication (such as amiodarone).
Consider effect of high altitude on oxygenation.
Take medicine in cabin luggage in the plane, carry list of treatments and the dosage with the generic name.
Refer to local country specific driving regulations regarding ICD.
Provide advice regarding flight security devices in presence of ICD.
Sleep and breathing
Recognize sleeping problems and HF sleep-related issues and how to optimize sleep.
Provide advice such as timing of diuretics, environment for sleep, device support.
In presence of sleep-disordered breathing provide advice on weight reduction/control.
Be reassured about engaging in sex, provided sexual activity does not provoke undue symptoms.
Recognize problems with sexual activity, their relationship with HF and applied treatment and treatment of erectile dysfunction.
Provide advice on eliminating factors predisposing to erectile dysfunction and available pharmacological treatment of erectile dysfunction.
Refer to specialist for sexual counselling when necessary.
Understand that depressive symptoms and cognitive dysfunction occur more frequently in people with HF, and that they may affect adherence.
Recognize psychological problems which may occur in the course of disease, in relation to changed lifestyle, pharmacotherapy, implanted devices and other procedures (including mechanical support and heart transplantation).
Regularly communicate information on disease, treatment options and self-management.
Involve family and caregivers in HF management and self-care.
Refer to specialist for psychological support when necessary.
Which professional groups should be involved?
cardiologists with special interest and expertise in HF in a tertiary or secondary care center,
cardiologists, specialists for internal medicine or general practitioners with special interest in HF in primary care,
HF specialist nurses.
In-depth training in HF, it’s causes, natural history, prevention, diagnostics, evidence-based treatments for individual patients according to guidelines including pharmacological and non-pharmacological therapy, devices and surgery with a special emphasis on drug titration.
Competency training in performance of clinical assessments and evaluation of symptoms and effects of treatment.
Competency training in assessment of educational and psychosocial needs and providing patient education.