Do All Patients With Heart Failure Benefit From a Program for Early Follow-up After Hospital Discharge ? Seguimiento mediante programas especı́ficos de consulta precoz tras el alta de un episodio de insuficiencia cardiaca : ? en todos los pacientes ?

Without a doubt, heart failure (HF) is one of the most important medical problems—even beyond the cardiologic setting—that we are facing today. Because of the ever-increasing life expectancy of the population and advances in the treatment for acute cardiologic conditions, the prevalence of HF is rising, with a current estimated rate in Spain of 4% to 7%. This condition is the main cause of hospitalization in the very elderly population, and it requires considerable health expenditure and resource use. Despite the widespread belief that HF is simple and easy to resolve, it is actually a complex syndrome that is challenging to diagnose and treat. Although spectacular progress has been made in HF care over the last few years, as reflected in clinical practice guidelines, this disease remains an important cause of hospitalization, markedly impairs the quality of life of affected patients, and is associated with high mortality rates. If factors such as the current characteristics of real-world HF patients—increasingly older, more frail, and with a higher prevalence of comorbidities—are added to the complexity of HF management, it is easy to understand why this condition creates a huge demand on the health system and affects all health areas and professionals, not only cardiologists. These factors may help to explain why adequate care by specialists limited to the hospital setting does not offer a definite solution to the problem. A more integrated approach is needed, in which the care provided is configured within interdisciplinary HF programs and units. This strategy is supported by scientific evidence documenting the prognostic benefit of this type of organizational approach. In the HF guidelines of the European Society of Cardiology published in 2016, the organization of HF care within multidisciplinary teams was assigned a class I A recommendation. Numerous studies and meta-analyses have reported the effectiveness of programs based on HF units for reducing readmissions and even mortality rates. In Spain these programs have been developed by proactive rather than institutional efforts, and they coexist with advanced units that arose in relation to cardiac transplant. Due to the individual initiatives of many centers with professionals interested in HF, and the structured programs organized by the Heart Failure Section of the Spanish Society of Cardiology, increasingly larger numbers of hospitals are equipped with HF units, and they are now becoming commonplace in both cardiology and internal medicine departments. Within its SECExcellence program, the Spanish Society of Cardiology recently established a new nomenclature for the various types of cardiology units (community, specialized, and advanced), depending on the level, equipment, and services portfolio offered by the hospital, cardiology department, and HF unit. In addition, a series of minimum standards have been established (related to processes, infrastructure, human resources, equipment, and results), which must be met by these units and departments to receive SECExcellence accreditiation. This is important to ensure the quality of HF care at all levels and to guarantee the development and implementation of these units in the Spanish health system. As mentioned, HF units provide benefits for both patients and the health system, with reductions in the number of readmissions and in some studies, decreases in mortality. Nonetheless, most of the studies evaluating these aspects, particularly those in the cardiology setting, mainly include HF patients with a low ejection fraction, age that is not too advanced, and a low prevalence of comorbidities. One aspect that clearly influences this choice of participants is that it is impossible to follow up all HF patients within intensive programs in units with a limited infrastructure. However, another factor to consider is that one of the basic benefits of these programs is optimization of medication and other treatments with a favorable effect on the prognosis, which is only possible in HF with systolic dysfunction. To date, there are no treatments that improve the prognosis in HF with preserved ejection fraction. Furthermore, these latter patients tend to be older, more frail and have a higher prevalence of comorbidities, factors that often limit optimal use of drug therapy and make integrated treatment difficult. However, some studies including patients with both preserved and reduced ejection fraction have reported that both types can benefit from specific treatment in specialized units. In their article published in Revista Española de Cardiologı́a, Pacho et al., of the Heart Failure Unit of Hospital de Badalona, a team with extensive experience in HF programs, confirm these results in the STOP-HF-CLINIC study, which includes a population of HF patients with unfavorable characteristics: very advanced age Rev Esp Cardiol. 2017;70(8):624–625