Heart failure (HF) is a severe clinical syndrome caused by a structural or functional cardiac anomaly that can be present before the onset of symptoms.1–4 “Stable” HF has classically been defined as the absence of clinical deterioration or changes in medication and an absence of hospitalizations.5 However, it is well known that HF with reduced ejection fraction (HFrEF) is a progressive disorder that is not always detected clinically.6,7 In fact, patients with “stable” HF have a 1-year all-cause mortality rate of 7.2% and a 1-year hospitalization rate of 31.9%.8,9

Managing HF is complex due in part to the presence of comorbidities.10 The treatment algorithm for patients with HFrEF includes angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II-receptor blockers (ARBs), beta blockers and aldosterone antagonists. In recent years, 2 new drug treatments have emerged for HFrEF: ivabradine and angiotensin receptor-neprilysin inhibitor (ARNI).1,2 Although the survival of patients with HFrEF has improved in recent years, the results are still insufficient.2,11 Given the need to raise awareness about the risk these patients present and to better understand the diagnostic and therapeutic management of this disease by clinical cardiologists, we conducted this study to establish recommendations on improving the management of outpatients with HF.

Supplementary Table 2 shows the panelists’ characteristics. Twenty-four percent of the participants had more than 20 years of professional exercise caring for patients with HF, with a mean of 3.41 days of consultations per week. Fifty-eight percent cared for 16–50 patients with HF per month. The panelists indicated that 55.7% of the patients they treated had “stable” HFrEF.

Supplementary Tables 3–5 show the complete results of the Delphi questionnaire, while Tables 1 and 2 show the statements for which consensus in agreement or disagreement was achieved after the 2 rounds, divided according to the various analyzed blocks. In the first round, the panelists achieved consensus on 59 statements (46 in agreement and 13 in disagreement). The 16 remaining statements were subjected to a second round of votes. In the second round, consensus was reached on 6 of the 16 reconsulted statements (3 in agreement and 3 in disagreement). Therefore, by the end of the Delphi process, consensus was reached on 65 statements (49 in agreement and 16 in disagreement), with 10 statements undetermined. The tables indicate the significance of the Bowker test for comparing the results of the 2 rounds (a p-value <.05 indicated that the responses of the 2 rounds were significantly different).

In terms of the definition and perception of patients with “stable” HFrEF (Table 1, Fig. 1), there was a high degree of consensus in terms of the definition of “stable” HF (82% of panelists) and that HFrEF has a silent nature that can increase the mortality risk for patients who are asymptomatic or mildly symptomatic (96%). There was also a high degree of consensus in disagreement in that patients with symptomatic HF do not have a considerable mortality risk if they do not present marked signs and symptoms of HF (95.3%).

Fig. 1.

Percentage of consensus in agreement on the definition of heart failure and on the nature of “stable” heart failure.

Abbreviations: ACC/AHA/HFSA: American College of Cardiology/American Heart Association/Heart Failure Society of America; ESC: European Society of Cardiology; HF: heart failure; HFrEF: heart failure with reduced ejection fraction.

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With regard to the management of patients with “stable” HFrEF (Table 2, Figs. 2 and 3), there was broad consensus in that cardiologists and primary care physicians should fully cooperate in the follow-up of these presumably “stable” patients (99.3%), that nursing plays a key role (96.7%) and that having a reference HF unit can be useful (94.7%). There was also a high degree of consensus in that the drug treatment should be optimized, even when the patients with HFrEF remain in the same functional class (98.7%), and that the need for adding or increasing a diuretic indicates that the patient has ceased being stable (79.3%). There was a high degree of consensus in disagreement regarding the notion that it is not necessary to assess in consultation whether the patient with “stable” HFrEF adjusts their life as their physical capacity reduces (96.7%) or that treatment with ARNI for patients with “stable” HFrEF is justified only when there is a worsening of the functional class (90.7%).

Fig. 2.

Percentage of consensus in agreement on the assessment, follow-up and treatment of “stable” HFrEF.

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; FC, functional class; HFrEF, heart failure with reduced ejection fraction.

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Fig. 3.

Percentage of consensus in agreement on the overall approach for “stable” HFrEF.

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Mortality for HFrEF remains high, and therefore improving its management is essential. This study shows the consensus that “stable” HFrEF is not a banal process but rather one that is associated with a high risk of disease progression. Raising the awareness of healthcare practitioners as to this fact is therefore necessary, as is the consequent need to optimize the treatment and follow-up of these patients.

One of the most relevant aspects revealed by this study’s results is the lack of agreement regarding the definition of “stable” HFrEF, given that consensus in agreement was reached in only 1 of the 3 definitions, which indicates that the current understanding of this entity is truly uncertain. This lack of consensus might be due, among other reasons, to the fact that “stable” HF as such does not exist, because in reality HF continues to progress.16–18 On this issue, the experts reached consensus in that disease progression can occur without changes in the functional class, given that progression is not directly related necessarily with functional class. The NYHA classification was also considered by the panelists as a subjective assessment of the patient’s symptoms and exercise capacity, given the lack of correlation between the NYHA functional class indicated by the physician and that considered by the patient.19 Therefore, assessing patients with HF through the simple functional class assessment could be insufficient. In short, these results lead to the notion that for experts the concept of stability in HF is incorrect. Rather, HF is a chronic disorder with periodic destabilizations that requires treatment optimization.

Another relevant aspect is that despite the fact that numerous studies have shown a high risk of sudden death in patients with HFrEF and a not very advanced functional class,17,18 the expert panel did not reach consensus on this issue, which could lead to a lack of treatment optimization.

A question that typically arises among physicians who treat patients with HF is whether patients who require diuretics to maintain the euvolemic state should really be considered “stable”. In fact, the expert panel did not reach consensus on this point, only that an increase in loop diuretic dosage indicated that the patient ceased to be “stable”. However, studies have indicated that patients with no signs of congestion who are treated with larger dosages of diuretics have higher mortality.20,21 Therefore, a patient who requires diuretics should not be considered a “stable” patient.

To optimize patient follow-up, a proper and timely patient assessment is required. The NICE guidelines recommend examining patients with “stable” HF at least every 6 months.5 In our study, the experts reached a high consensus in agreement with this recommendation. The panel also reached a consensus that performing a basic clinical assessment is insufficient and that patients should be asked during each visit whether they have had “new” symptoms and whether they have adjusted their life to these symptoms.

The current clinical practice guidelines recommend measuring natriuretic peptide levels to assess disease severity, establish the prognosis and prevent the progression of HF.1,2 The reduction in natriuretic peptide levels with treatment has been associated with lower HF mortality and lower hospitalization rates.22,23 In this respect, the experts achieved consensus on the need for measuring biomarker levels during follow-up, which could help optimize the treatment.

A low distance travelled in the 6-min walk test is an unfavorable prognostic marker of HF,2 and there is an inverse correlation between the functional class and distance travelled.24 However, the experts did not reach consensus on the need for the 6-min walk test for the patient’s clinical assessment in clinical cardiology consultations. The experts also considered that cardiac magnetic resonance imaging was not an essential technique for assessing stable HFrEF. Despite the fact that cardiac resonance imaging provides relevant information, it was not considered essential, especially for the follow-up.2,25 Although appropriate treatment of HF can improve the ejection fraction26 and lack of improvement is associated with a poorer prognosis,27 the experts did not reach consensus on the need for measuring the ejection fraction during the follow-up. Accordingly, the need for optimizing the treatment of HF will probably not depend on imaging tests as much as on clinical assessments.

The experts reached consensus in agreement with all statements related to the follow-up from the various healthcare departments, confirming that the follow-up of patients with HFrEF should be coordinated between the various healthcare levels, promoting continuous medical education necessary for improving the management of these patients.2,3 Appropriate coordination between the healthcare levels has been shown to improve the prognosis of patients with HF and reduce hospitalizations.28 Moreover, the clinical management depends on the healthcare resources and organization and should be adapted to each patient’s characteristics.29 The clinical cardiology section is developing the Management of Heart Failure in Cardiology and Primary Care (MICCAP) program, whose main objective is to improve the coordination between primary care and cardiology to improve the care of patients with HF.30

The objective of optimized treatment is to slow the disease progression and to improve the patients’ quality of life and prognosis.2,31 Thus, the experts reached consensus that a change in treatment needs to be assessed, regardless of the patient’s alleged clinical stability and maintenance of their functional class. For example, the expert panel reached consensus that the change from an ACEI or ARB to an ARNI should not be delayed until a clinical decompensation or worsening of the functional class, given that this is associated with a poorer prognosis and loss of opportunity for optimizing the treatment in the consultation. In fact, ARNIs have been shown to be superior to ACEIs (enalapril) in reducing the risk of mortality and hospitalization for patients with HFrEF who were mostly in NYHA functional class II/IV32,33 and is one of the recommendations in the clinical practice guidelines.2,31

As with other studies with a similar design, this study had a number of potential limitations worth mentioning. The experts were selected only from Spain, and all panelists were within the specialty of clinical cardiology. Although this could entail a certain territorial or specialty bias, the panelists were chosen for being experts on the subject. This consensus therefore did not consider the opinion of other practitioners who might also have contact with this disease. Lastly, the study’s strengths include the large number of participants (150 experts) and the recognized usefulness of the Delphi method for reaching conclusions, given that it ensures anonymity and that participants have sufficient time for individual reflection, minimizing the bias of interpersonal influence and time pressures.12

The concept of “stable” HF is not well-recognized among all experts and encourages therapeutic inertia. HF is a progressive disease, even for the patient group theoretically considered “stable”. Treatment optimization should therefore be assessed in each consultation and not postponed until there is a worsening of symptoms. The results of this Delphi study help prepare proposals for improving the care of outpatients with HFrEF.

The study sponsor was the Research Agency of the Spanish Society of Cardiology, which was given an unconditional grant from Novartis.

The authors declare that they have no conflicts of interest.