Integrated Care for Heart Failure in Primary Care

摘要: Chronic heart failure (CHF or simply HF) is a complex clinical syndrome that involves more than 2% of the general population and over 10% older people. For people with reduced ventricular function (the classical HFrEF phenotype), guidelinedirected medical therapy (GDMT) (e.g., Ace-inhibitors, beta-blockers, diuretics, rehabilitation implantable devices) demonstrated to be efficacious in reducing hospitalisations prolonging survival. Vice-versa, HF preserved ejection fraction (diastolic HFpEF phenotype) much syndrome, which co-morbidities (such as COPD, depression, anemia, diabetes, CAD) play significant role decompensation episodes. As ages, phenotype becoming frequent puts management problems, since conventional less control symptoms. A multidisciplinary managed approach, based on principles Care Model, most effective tool ensure best social outcomes, for both phenotypes. It critical every health worker should use counselling tools, such how recognise characteristics disease early signs whereby manage them, proper each drug modify progressing risk factor, improve compliance patients toward self-management empowerment. Finally, we propose plan care affected HF, allows integration teams ensures complete appropriate cases, respect therapeutic responsibility entrusted GP.