The emerging role of advanced practice nurses in cardiogeriatrics

Background

Heart failure (HF) in older adults is characterized by multimorbidity, frailty and cognitive decline, challenging conventional cardiology paradigms. Hospital-centered approaches often fail to address functional vulnerability and continuity needs, leading to suboptimal implementation of guideline-directed medical therapy (GDMT). Integrating Advanced Practice Nurses (APNs) into cardiogeriatric pathways represents a pragmatic strategy to operationalize multidisciplinary, person-centered care and close the persistent evidence-to-practice gap in HF management.

Purpose

To describe the design and early outcomes of a nurse-led, multidisciplinary cardiogeriatric model in which APNs coordinate HF management for older adults across hospital, day-hospital and telemonitoring settings.

Methods

A structured cardiogeriatric program was implemented within a tertiary care network, embedding APNs as clinical and organizational leaders. The model combines:

• Day-hospital programs for GDMT titration, intravenous diuretics and iron therapy.

• Bedside education to reinforce adherence and caregiver participation.

• Pre-interventional geriatric assessment for patients considered for advanced HF therapies.

• Telemonitoring coordination through a digital platform enabling rapid response to alerts and outpatient intervention.

APNs conducted standardized frailty, nutritional and cognitive assessments, delivered patient education, optimized therapies under cardiologist supervision, and ensured seamless communication with primary and community care teams.

Results

The program proved feasible and sustainable. APNs became central to therapy optimization, congestion management and telemonitoring oversight, acting as key interfaces between cardiology, geriatrics and home-based care. Their integration enhanced interprofessional collaboration, shortened decision timelines and improved care continuity after discharge. The model fostered adherence, patient engagement and functional stability, while supporting safe outpatient management and reducing unnecessary hospital dependence.

Conclusion

Embedding APNs within cardiogeriatric HF pathways is feasible, safe and transformative. This nurse-led model bridges cardiology and geriatrics, advances ESC 2021 recommendations for integrated and multidisciplinary HF care, and promotes age-friendly, person-centered practice. It offers a scalable framework for healthcare systems facing population aging and workforce constraints, underscoring the strategic contribution of advanced nursing practice to sustainable HF management.For image description, please refer to the figure legend and surrounding text.