Insuficiența Cardiacă Cronică și Acută la Adult

Objectives

Moldova’s National Clinical Protocol on chronic and acute heart failure in adults aims to improve the quality of care and treatment outcomes across all stages of care, using evidence synthesised from the 2021 European Society of Cardiology guideline to support individualised preventive, diagnostic and therapeutic decisions.[1][2]The protocol seeks to reduce mortality, hospitalisation, repeated admissions, intensive-care duration and length of stay, while improving symptom control, functional capacity and quality of life.[2][3]

• Strengthen prevention and early detection by identifying people at risk, managing hypertension, diabetes, dyslipidaemia, coronary disease, obesity, smoking, harmful alcohol use and sedentary behaviour, and preventing progression from risk states to symptomatic and advanced disease.[4][5][6]
• Standardise diagnosis and classification through clinical assessment, electrocardiography, natriuretic peptides, echocardiography, laboratory testing and targeted imaging, including classification by left-ventricular ejection fraction and disease stage.[7][8][9]
• Deliver phenotype-specific treatment for heart failure with reduced, mildly reduced and preserved ejection fraction, including evidence-based medicines, diuretics for congestion, devices, revascularisation or valve intervention where indicated, and treatment of underlying causes and comorbidities.[3][10][11][5]
• Provide integrated management for acute heart failure by rapidly identifying reversible causes, relieving congestion, restoring oxygenation and perfusion, stabilising haemodynamics, preventing organ injury and planning safe discharge and follow-up.[12][13]
• Support advanced-heart-failure referral, mechanical circulatory support, transplantation assessment, renal-replacement strategies and palliative care according to prognosis, clinical profile, patient preferences and eligibility.[14][15][16][17]
• Promote multidisciplinary, patient-centred care, self-management, education, rehabilitation and support for families and carers, including end-of-life planning where appropriate.[18][19][20]

Implementation

The protocol organises care across emergency medical assistance, primary care, specialised outpatient consultation, hospital services and higher-level cardiology or specialised clinical departments.[21][2]Clinical decisions should be made through consultation between responsible health professionals, patients and, where appropriate, carers, with professional judgement adapted to the individual’s health status and applicable prescribing rules.[1]

• Deliver primary-care prevention, screening, clinical assessment and timely cardiology referral for suspected heart failure, with urgent hospital admission for suspected acute presentations.[22][23]
• Use coordinated outpatient, inpatient and specialist services to initiate, optimise and continue treatment, supported by discharge documentation containing diagnosis, investigation results, patient recommendations and recommendations for the family doctor.[24][25]
• Implement multidisciplinary heart-failure programmes through clinic-based, home-care or hybrid models, adapting organisation to available infrastructure, workforce, financing, administrative arrangements and patient needs.[18][19]
• Provide patient and caregiver education on disease understanding, medicine adherence, symptom recognition, diet, fluid and salt intake, daily weight, physical activity, smoking cessation, immunisation and when to contact health services.[20][26][27]
• Monitor chronic heart failure through reviews generally at intervals shorter than six months, with closer follow-up after discharge or during dose titration; assess symptoms, vital signs, blood count, electrolytes and renal function, perform annual electrocardiography, and repeat echocardiography when clinical status worsens or after treatment optimisation when needed for device decisions.[28]
• Use telemonitoring as an adjunct to existing care, collecting information such as symptoms, weight, heart rate and blood pressure, with healthcare staff providing treatment adjustments or additional advice.[29]
• Refer advanced cases to specialised centres capable of advanced therapies, with urgency informed by recurrent admissions, organ function, congestion, exercise capacity, nutritional status and clinical deterioration.[14][30]
• Maintain defined service capacity across levels of care, including cardiology and nursing staff, diagnostic and laboratory services, oxygen and resuscitation capacity, cardiovascular medicines, monitoring technologies and selected device or intervention services.[31][32][33]

Governance includes preparation by cardiology specialists and researchers at the Institute of Cardiology, with discussion, approval and countersigning involving specialist commissions, the Agency for Medicines and Medical Devices, the National Health Insurance Company and the Ministry of Health’s Council of Experts.[34]The protocol has been updated in 2012, 2014, 2017 and 2023, with the next review scheduled for 2028.[34]

Quality assurance uses standardised criteria-based audit forms and indicators drawn from clinical records and registers.[35][36][37]Indicators cover standard examinations, cardiovascular-risk assessment, correct diagnosis, continuous treatment, treatment modification, patient education, clinical stability, emergency use, complications, mortality, intensive-care duration, non-invasive monitoring, coronary angiography and revascularisation.[35][38][39][40][41]The supplied material does not specify budgets, financing sources, cost estimates or resource allocations.[32]

Monitoring & Evaluation

The protocol combines document-level quality measurement, standardised clinical audit and patient-level monitoring across chronic, acute and advanced heart failure care. Its quality framework prioritises standard assessment, documented cardiovascular-risk assessment and diagnosis, continuous treatment, treatment modification, patient education, clinical stability, complications, hospital mortality, intensive-care use, and use of specified acute-care interventions.[35][38][39][40]

• Measure chronic-care performance as percentages of supervised patients receiving a standard examination within six months, documented risk assessment and correct diagnosis, continuous treatment, appropriate treatment modification, stable disease, risk-factor education, and attendance at the heart-failure patient school.[35][38][42]
• Calculate most indicators from defined numerators and denominators, generally for the preceding year, while the documented education measure uses the preceding three months; intensive-care duration is measured as total hours divided by the number of acute-heart-failure patients.[39][40][41]
• Use medical records, supervision registers, patient-visit documentation and patient-school registers as the principal data sources for these indicators.[35][38][42]
• Track acute-care outcomes and activity through emergency-assistance requests for exacerbation, protocol-compliant follow-up, exacerbations, renal-function deterioration, in-hospital mortality, intensive-care duration, non-invasive monitoring, coronary angiography, revascularisation and other invasive procedures.[39][43][40][41]

Clinical monitoring is integrated into delivery. For chronic heart failure, reviews should occur at intervals shorter than six months, with closer follow-up after discharge or during dose titration; core assessments include symptoms, heart rate and rhythm, blood pressure, full blood count, electrolytes and renal function.[28]Annual electrocardiography and targeted repeat echocardiography are identified, including reassessment after three to six months of optimised treatment in reduced-ejection-fraction heart failure when further treatment or device decisions are required.[28]

• Monitor serum creatinine, sodium and potassium every three months in patients under heart-failure surveillance, and check blood pressure after each dose increase of angiotensin-converting enzyme inhibitor or angiotensin-receptor antagonist therapy and beta-blockers.[44]
• Support self-monitoring through daily weight measurement and action when weight rises by more than 2 kilograms within three days, alongside recognition of worsening breathlessness, oedema and congestion.[45][27]
• Use telemonitoring to collect symptoms, weight, heart rate and blood pressure, with healthcare staff providing treatment adjustment or advice; it is intended to complement, rather than replace, existing services.[29]
• Assess telemonitoring using mortality and heart-failure hospitalisation as principal outcomes; cited evidence is mixed despite a 2017 Cochrane review associating telemonitoring with lower all-cause mortality and heart-failure hospitalisations.[29]

Acute heart-failure monitoring spans pre-hospital, hospital and discharge stages. Pre-hospital assessment includes pulse oximetry, blood pressure, heart rate, respiratory rate and continuous electrocardiography, while inpatient monitoring covers vital signs, cardiac rhythm, haemodynamic and respiratory status, oxygenation, perfusion, congestion and hypoperfusion.[46][13][47]Patients should be reassessed for residual congestion and medication tolerance within one to two weeks after discharge.[48]

Standardised criteria-based audit forms strengthen case-level documentation for both outpatient chronic and inpatient acute heart failure. They record clinical classification, investigations, referrals, treatment, adverse effects, complications, follow-up, counselling, outcomes, discharge or death, responsible staff and institutional details.[49][50][51][52]Treatment results may be recorded as improvement, no change, progression, complications or unknown.[53][54]The extracts do not specify reporting schedules, performance targets, audit frequency, named accountability bodies or a wider surveillance system.[35][39][52]

Costing & Financing

The protocol identifies substantial human, technological and treatment-resource requirements for heart-failure care, but does not provide cost estimates, budgets, allocations, financing sources, funding gaps, resource-mobilisation plans or economic assumptions.[55][32][56]

• Require capacity across primary care, consultative-diagnostic services, territorial hospitals and specialised republican cardiology services, including cardiologists, functional-diagnostics clinicians, cardiac surgeons, interventional specialists, nurses, laboratory and imaging services.[55][32][33]
• Provide diagnostic, monitoring and emergency capacity including echocardiography with Doppler, exercise testing, electrocardiographic and blood-pressure monitoring, telemonitoring, magnetic resonance imaging, computed tomography, angiography, angioplasty, laboratory services, oxygen therapy and resuscitation equipment.[32][33]
• Support treatment capacity for cardiovascular and emergency medicines, intravenous vasodilators, pacing and defibrillation devices, revascularisation, valve interventions, ultrafiltration, haemodialysis and advanced mechanical-support technologies.[31][56]

Multidisciplinary heart-failure programmes should be adapted to available infrastructure, facilities, workforce, financing, administrative policies and patient needs.[18]Telemonitoring may reduce patient transport expenditure and hospital presentations, but the comparative effectiveness and cost-efficiency of different models require consideration; no local economic evaluation or funding model is supplied.[29]

Several technologies or medicines are noted as unavailable in the Republic of Moldova, including MitraClip, ventricular-assist devices, an artificial heart and cardiac transplantation.[56]Mechanical circulatory support and transplantation-related options are also described as unavailable in the country in the advanced-heart-failure recommendations.[57]Dapagliflozin, empagliflozin and certain other starred medicines are reported as not registered in the State Nomenclature of Medicines, while ferric carboxymaltose is reported as unavailable.[10][58][59]

No explicit machine-readable cost items are provided.[60][32]