Disease management of chronic heart failure

Abstract

For the optimal management of heart failure, multidisciplinary teams should apply evidence-based therapy with the patient in the center of care. It includes patient-clinician cooperative monitoring, shared-decision making, telemonitoring and implementation of well-established clinical pathways. In this thesis, we have assessed key elements of telemonitoring of stable chronic heart failure patients and the impact of implementation of a multidisciplinary clinical pathway for patients with heart failure caused by cardiac amyloidosis. With a systematic review, we could show that there is considerable heterogeneity among telemonitoring programs and patient management protocols that are currently used. If well-organized, telemonitoring can safely substitute the number of heart failure nurses’ face-to-face contacts with patients. We could show this indirectly; the change (delta) in circulating natriuretic peptides levels in the first year after initiation of a telemonitoring program aimed at substitution of the intensive usual care was safe while reducing health care utilization of stable heart failure patients. Next, we investigated the use of a telemonitoring platform and identified several important aspects with regard to patient adherence. Patients were most adherent to weight transmissions. However, adherence decreased over the year, while clinical and demographic variables were not related to adherence. Finally, we investigated the impact of the implementation of the ‘Utrecht multidisciplinary clinical pathway for amyloidosis’. After implementation, we observed a positive impact on awareness among referring Dutch cardiologists and improvement in diagnostic delay, resulting in a lower disease severity at diagnosis of patients. In conclusion, our results emphasize that eHealth could be helpful in the management of the growing number of patients with heart failure, and that a structured care pathway is useful in the management of patients with cardiac amyloidosis.