Inam Maha, Sangrigoli Robert M, Ruppert Linda, Saiganesh Pooja, Hamad Eman A
Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19147, USA.
J Cardiovasc Dev Dis. 2025 Aug 5;12(8):302. doi: 10.3390/jcdd12080302.
Heart failure (HF) is a major global health challenge, characterized by high morbidity, mortality, and frequent hospital readmissions. Despite the advent of guideline-directed medical therapies (GDMTs), the burden of HF continues to grow, necessitating a shift toward comprehensive, multidisciplinary care models. Heart Failure Disease Management Programs (HF-DMPs) have emerged as structured frameworks that integrate evidence-based medical therapy, patient education, telemonitoring, and support for social determinants of health to optimize outcomes and reduce healthcare costs. This review outlines the key components of HF-DMPs, including patient identification and risk stratification, pharmacologic optimization, team-based care, transitional follow-up, remote monitoring, performance metrics, and social support systems. Incorporating tools such as artificial intelligence, pharmacist-led titration, and community health worker support, HF-DMPs represent a scalable approach to improving care delivery. The success of these programs depends on tailored interventions, interdisciplinary collaboration, and health equity-driven strategies.
心力衰竭（HF）是一项重大的全球健康挑战，其特征为高发病率、高死亡率以及频繁的住院再入院情况。尽管有了指南指导的药物治疗（GDMTs），HF的负担仍在持续增加，这就需要转向全面的多学科护理模式。心力衰竭疾病管理项目（HF-DMPs）已成为一种结构化框架，整合了基于证据的药物治疗、患者教育、远程监测以及对健康社会决定因素的支持，以优化治疗效果并降低医疗成本。本综述概述了HF-DMPs的关键组成部分，包括患者识别与风险分层、药物优化、团队式护理、过渡性随访、远程监测、绩效指标以及社会支持系统。HF-DMPs纳入了人工智能、药剂师主导的滴定以及社区卫生工作者支持等工具，代表了一种可扩展的改善护理服务的方法。这些项目的成功取决于量身定制的干预措施、跨学科协作以及以健康公平为导向的策略。
