Searching for dose-response in HF clinics

The study of Strömberg and colleagues1is one of the first studies to describe the effectiveness of a nurse-led heart failure clinic in decreasing mortality. Although several studies on heart failure management programmes have shown promising results in decreasing readmission and improving quality of life, effects on mortality have usually been inconclusive.2,3The intervention tested by Strömberget al. consisted of optimizing medication, patient education and psychosocial counselling. Compared to patients in the control group, patients who attended the heart failure clinic received more optimal doses of ACE-inhibitors and improved self care. The way the data are represented, however, makes it difficult to determine what the most effective component was. In their paper, the authors primarily attribute the success of their heart failure clinic to increased self-care of patients and do not discuss the role of optimal titration of ACE-inhibitors. Secondly, the authors described that the intensity of the intervention varied substantially in their patient population. Most of their patients (28) visited the heart failure clinic once, 12 patients came twice and the rest of the patients paid three to eight visits. Four patients did not have any clinic visit at all and had only contact to the nurse by telephone. It can be questioned what the optimal dose and mode of contact is (e.g telephone contact, clinic visit or home visit) for these patients. As discussed by the authors, the number of included patients is rather small, making it impossible to perform analysis on the optimal ‘dose-response’ of this intervention. In other words it is not possible to answer the question if patients who only had telephone contact benefited as much from the intervention as patients that came to the clinic eight times did. For future planning of health care resources it will be vital to know if we can identify patients who are at risk for future deterioration and consequently intensify our patient education and follow-up for specific groups. To get more insight in such a ‘dose-response’ we recently started a multicentre randomized study in 1050 HF patients (COACH) in which advising and counselling in two different intensities will be compared to follow-up without a heart failure nurse.4With this trial we aim to find out the most optimal intensity of care and follow up that is needed to achieve the maximum results. In that way we hope to contribute to provision of optimal care to the growing group of heart failure patients in a time of limited recourses.