How to fill the gap in the symptomatic HF patient journey between optimal medical therapy and advanced heart failure treatment: two Italian surveys
Authors: Spadotto A , Ziacchi M , Ghio S , Pellegrino M , Masarone D , Caracciolo M , Inserra C A , Ammirati F , Ciccarelli M , Colivicchi F , Bianchi S , Oliva F , Biffi M , Sinagra G 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Heart failure (HF) is the pandemic of our century and an estimated 64.3 million people are living with HF worldwide. New therapies alongside the old ones have been recently introduced in clinical practice with good results but the prognosis for a high percentage of patients remains poor with a high mortality rate and markedly reduced functional status.

Purpose
This study aims to investigate through two surveys what physicians think are the current needs in HF management to gain insight into the epidemiology and characteristics of patients followed by Italian HF outpatient clinics. In particular, we evaluated the gap that Cardiac Contractility Modulation (CCM) could fill in HF management in a real-world scenario.

Methods
a 20-question survey on HF management in different scenarios addressed to all physicians operating in Italian centers involved in HF care was published on the website Cardioinfo. A second survey was sent to Italian high-volume referral outpatient HF clinics. The participating centers were asked to collect the number of patients admitted during 4 weeks and to fill out a 19 items survey regarding some characteristics of these patients.

Results
A total of 105 physicians (77% cardiologists) and 14 high-volume referral outpatient HF clinics took part in the surveys. Despite regular clinical follow-up at 3-6 months in 94% of cases, the currently available medical therapy is considered insufficient in stabilizing HF patients in 30% of cases. 23% of physicians perceive to have a lack of treatment options in symptomatic patients with reduced ejection fraction and this percentage rises to 66% in patients without reduced ejection fraction (Figure 1). Cardiac contractility modulation is considered a valid option by 15% of physicians. According to Food and Drug Administration criteria, in the cohort of patients referred to HF clinics around 3% of patients are suitable for CCM implantation (2 patients a month per heart failure outpatient clinic), but considering additional selection criteria the percentage of patients eligible may increase to 5-6%.

Conclusions
The surveys confirm the significant attention paid to HF in Italian hospitals, however the lack of therapeutic options for a non-negligible number of patients, who are clinically evaluated regularly, but without associated substantial changes in therapy, leads to frustration for the patient and the physician, and an increase in costs for the health care system. A relatively small percentage of the total HF population fulfills the indication for immediate CCM treatment. Nevertheless, considering the size of the HF population, CCM, reducing hospitalizations, improving functional capacity and QoL may be of key importance for many HF patients, especially the elderly.