To understand what the term heart failure clinic means in most settings, it is necessary to understand what the goals are in setting up such clinics. Often, the motivation for their development has been an awareness of the frequency of hospitalization and subsequent repeated hospitalizations for many patients with heart failure These hospitalizations frequently involve patients within a capitated reimbursement structure. Care within an academic medical center and the frequent presence of other diseases in patients with advanced heart failure predispose to longer hospital stays and increased costs, which are further increased by the fact that illness is often severe and patients are generally older. The heart failure clinic, then, is often the outgrowth of an institutional task force concerned with the costs of caring for patients with a chronic disease. Targeted activities for the heart failure clinic are straightforward and include, as a baseline, patient education (2) and optimal utilization of standard medical therapy (3). On rarer occasions, the heart failure clinic is developed as part of a prospective approach to offering comprehensive care for a specific disease or population. Regardless of the approach used to initiate a heart failure clinic, they are all similar in structure and function. Typically, a nurse is selected as the initial team member to investigate or initiate development; on occasion, the initial facilitator is a physician.

An extremely wide variety of approaches have been utilized throughout the United States. This is a reflection of the varied needs and resources available to individual institutions and practices. Therefore, the term heart failure clinic means different things to different people. The spectrum of services that may be offered in a heart failure clinic or program are listed in Table 37-1. Utilization of a
protocol often facilitates the upward titration of drugs such as β-blockers and enhances the ability to attain target doses. For example, by using the protocol set forth in Appendix I, we successfully initiated carvedilol treatment in several hundred patients and target doses were attained in more than 90% of them within a 60-day period. Careful attention to protocol details and the availability of nurses skilled in drug titration allowed for successful titration with a minimum of adverse events. Often, the patients were referred to the heart failure clinic only for the titration period.

Perhaps because of the difficulty of educating elderly patients who frequently have age-associated cognitive deficits or who are ill during a short hospitalization, education remains one of the critical services a heart failure clinic provides most patients (4).

No accurate count of the number of heart failure clinics within the United States is available; however, the current number has been estimated to be more than 150. Some detailed information about 59 of these clinics has been obtained by survey (5). Nearly half have been functional for more than 5 years and new clinics are being developed each year. These are predominantly multidisciplinary clinics with primary involvement of a nurse and a cardiologist. The average clinic manages approximately 150 patients and is staffed by three nurses along with ancillary personnel. Generally, the nurse is the primary organizer and developer of the clinic. Usually, after a brief fact-finding period and a review of the financial impact of heart failure on an institution, a decision is made and resources are allocated to the development of a clinic. Depending on an institution’s experiences and resources, the clinic is usually based in an out-patient setting, although this is not always the case. Some institutions may allocate telemetry beds in a hospital unit or even bays in an emergency department to administer intravenous diuretics to decompensated patients, with the goal of preventing repeated admissions. One commonly administered treatment, as yet unproven by randomized clinical research trials, is out-patient inotropic therapy. In fact, 68% of surveyed heart failure clinics utilize infusions of inotropic agents as an approach to the treatment of patients with heart failure (5). The focus of a heart failure clinic might affect its location and facilities. Usually, however, there is an area in or adjacent to the hospital where patients may come on an elective basis for education, dietary instruction, exercise, and supervision. Clinics usually are the outgrowth of an area of expertise and interest, such as cardiac or pulmonary rehabilitation, that already exists within an institution, a cardiac support group, or a physician’s office.

Physical requirements similarly vary, and clinics may consist of little more than a telephone or may include an entire suite dedicated to heart failure-related activities. Generally, office space is needed for record storage and telephone communication along with clinical space for the evaluation and treatment of patients. Ideally, there should also be space reserved for patient education, conferences, and lectures as well as private patient-family meetings. Access to a library of heart failure-related materials and internet access are also extremely useful.

Because the average hospital has more than 500 primary heart failure admissions annually, perhaps one of the most difficult tasks is identifying which patients should be targeted for the heart failure clinic. Ideally, some strategy should be directed at improving the outcome of all patients with heart failure as well as those with asymptomatic left ventricular dysfunction and those at risk for the development of heart failure. However, at present most clinics focus on the patient with overt, symptomatic, and usually advanced heart failure. An obvious method to identify patients at highest risk for repeated in-patient admissions and resource utilization has been simply to consider those patients recently hospitalized with heart failure. Increasingly, patients admitted to a hospital with heart failure have very advanced symptoms and poor prognostic markers and, hence, are likely to be readmitted (6). In fact, readmission rates for these patients at 30 and 60 days approach 30% to 50% (7,8,9). Also, because databases of financial information are found predominantly within medical institutions, outcomes regarding hospital length of stay and readmission are often the easiest to track. However, many other patients may be suitable for enrollment in a heart failure clinic (Table 37-2). Some heart failure clinics are able to work closely with emergency departments (which are the source of most hospital admissions for heart failure) so that in some cases triage, treatment, and release are arranged by the heart failure clinic. This is obviously a good opportunity to enroll patients into the clinic population.