Beyond the pill: integrating multidisciplinary care team to implement individualised management strategies for patients with advanced heart failure

Background

Heart failure (HF) is a significant global health challenge due to its high mortality and re-hospitalisation rates. To address the complexities of HF, international guidelines recommend a multidisciplinary team management and collaborative care (Class IA). Data on advanced HF (AdvHF) multidisciplinary management program being led by HF specialty-trained nurses and collaboration with various specialists across boundaries remain scarce due to perceived higher risks and intensity of care required to be delivered.

Purpose

We evaluated the safety and efficacy of a multidisciplinary AdvHF program which were individualised for AdvHF patients (pts) being referred to our AdvHF centre.

Methods

The program included comprehensive baseline evaluations, namely echocardiogram, 6-minutes-walk test (6MWT), NTproBNP levels, Kansas City Cardiomyopathy Questionnaire (KCCQ), Frailty score, HF-associated hospitalisation (HFH). AdvHF pts underwent intensive monitoring and medications titration, together with supervised, centre-based exercise training, with additional health education on lifestyle changes, dietary counselling, training for activities of daily living, and stress management, all provided by a multidisciplinary team being led by HF nurse specialists and HF cardiologists, with physiotherapists, dietitians, occupational therapists and clinical psychologists. Retrospective evaluations of the program were conducted to assess the health outcomes of the participants, by comparing 1 year before enrollment and 1 year post program.

Results

A total of 103 advanced HF pts with mean LVEF 25.8±8.8% were enrolled and completed program from September 2021 to August 2025. Mean age was 53.5±10.5 years old (78% male; 28% ischemic cardiomyopathy).

Analysis of the post-program evaluations revealed significant improvements across several key health measures. 6MWT distances was increased by 8.5% (p<0.001), LVEF increased by 43.3% (25.8±8.8% vs. 37.0±12.0%), NT-proBNP level decreased by 38.8% (p<0.001). Quality of life, as measured by KCCQ showed a 12.1% improvement (p<0.001), while the frailty score decreased by 38.8% (p<0.01), suggesting enhanced physical resilience and improved overall well-being. Lastly, heart failure-related hospitalizations declined by 87.9% (p<0.001) following program completion.

Conclusion

Multidisciplinary approach with effective collaboration for AdvHF patients has led to significant enhancements in clinical outcomes, exercise capacity, quality of life, and reductions in HF hospitalisations. Such integrated, tailor-made, cross boundaries collaboration AdvHF program should be implemented with anticipated improved clinical outcomes and reduced healthcare burden and costs.For image description, please refer to the figure legend and surrounding text.