Project: The handbook

The handbook
The handbook is designed to help solve problems and drive change that will make a meaningful difference to care for people living with heart failure.

What is the handbook?

The handbook of multidisciplinary and integrated heart failure care is a landmark report from the HFPN, published in September 2018.

The handbook was produced to help patient advocates and healthcare professionals communicate a shared, compelling and evidence-based case for change in heart failure (HF) policy; to win the support of key decision-makers to challenge the status quo; and to encourage and facilitate more consistent implementation of best practice.

The needs of people with heart failure (HF) are not static, so there is no single optimal care journey. There are three very typical phases of HF: diagnosis; care and follow-up; and living with heart failure. Depending on progression of the syndrome, people with HF may have episodes that require return to acute care or enhanced medical supervision.

The handbook makes the case for best-practice multidisciplinary and integrated care throughout the care journey for the person with HF. It identifies key components of quality in HF care and the barriers to implementing best-practice care across Europe. The handbook is based around five ‘pressure points’ along the care journey:

  • Presentation and diagnosis
  • Discharge planning and early follow-up
  • Clinical management
  • Patient empowerment and self-care
  • Advance care planning.

Each pressure point is summarised in the handbook and also has a dedicated short report giving an overview of the issue, best practice, and case studies and reproducible tools.

Download the handbook

The handbook was produced in English and later translated into French and Spanish. The full-length versions of the five pressure points are available in English only. The HFPN has also produced a fold-out summary leaflet in English, French, Italian, Polish and Spanish.

The handbook

English: The handbook of multidisciplinary and integrated heart failure care English: single-page printable PDF French: Guide de prise en charge multidisciplinaire et intégrée de lʼinsuffisance cardiaque Spanish: Guía para la atención multidisciplinar e integral de la insuficiencia cardiaca

Pressure points

Pressure point 1: Presentation and diagnosis Pressure point 2: Discharge planning and early follow-up Pressure point 3: Clinical management Pressure point 4: Patient empowerment and self-care Pressure point 5: Advance care planning

Summary leaflet

English summary French summary Italian summary Polish summary Spanish summary

Call to action

In the handbook, the HFPN calls on governments across Europe to:

  • have a formal strategy on HF
  • invest in sustainable, specialist HF care models outside of acute care
  • ensure national guidelines and local care pathways embed the vision of quality in routine delivery
  • prepare robust and public national audits of performance to ensure accountability to citizens on patient survival, quality of life and experience of care, and to guide investment and incentives.

The call to action also requires governments to demonstrate measurable improvement for the following minim standards and core indicators of quality for all people with HF:

  • Specialist-led diagnosis with echocardiogram
  • Natriuretic peptide testing available in both primary and secondary care
  • Specialist-led care in hospital with input from a cardiologist and HF specialist nurse
  • Cardiac rehabilitation, patient therapeutic education and psychological support
  • A shift in management of HF from the acute setting to primary care.

Case studies

Click the map to sort the case studies by country or view all below

The following case studies are based on research that was conducted in 2018.
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Numerous organisations have pledged their support and endorsement of The handbook of multidisciplinary and integrated heart failure care, including:

Project Advisory Group

Dr Paola Antonini
Head of Clinical Research and Training, Associazione Italiana Scompensati Cardiaci (AISC) (Italy)
Dr Josep Comín-Colet
Cardiologist, Bellvitge University Hospital (Spain)
Dr Maria Rosaria Di Somma
Managing Director, AISC (Italy)
Professor Salvatore Di Somma
Sapienza University of Rome; Director Scientific Committee, AISC (Italy)
Michel Enckels
President, Mon Coeur Entre Parenthèses (Belgium)
Professor Andrzej Gackowski
Cardiologist, Jagiellonian University Medical College (Poland)
Professor Luc Hittinger
Cardiologist, Henri Mondor University Hospital (France)
Neil Johnson
CEO, West of Ireland Cardiac Foundation (Ireland)
Steven Macari
President, Association Vie Et Coeur (France)
Professor Anne-Catherine Pouleur
Cardiologist, Cliniques Universitaires Saint-Luc; President-Elect, Belgian Working Group on Heart Failure (BWGHF) (Belgium)
Yolanda Rueda
Secretariat, CardioAlianza (Spain)
Yolanda Rueda
President, CardioAlianza (Spain)
Dr Pierre Troisfontaines
Cardiologist, CHR de la Citadelle; Past-President, BWGHF (Belgium)
Professor Faiez Zannad
Cardiologist, CHU de Nancy; Director, CIC INSERM (France)


The handbook of multidisciplinary and integrated heart failure care made possible with financial support from Novartis Pharma. Additional support for the handbook launch in September 2018 was provided by Bayer AG.

As with all materials produced by HFPN, the handbook’s content is not biased to any specific treatment or therapy, and is endorsed and owned by the Network’s members, who have full editorial control. All members provide their time for free.

Related Articles

Heart Failure Policy Network presents handbook at event in Lisbon
Heart Failure Policy Network presents handbook at event in Lisbon
25th June 2019
The work of the HFPN was presented on 25 June 2019 at an event hosted by AADIC – the Portuguese Association of Support for Patients with Heart Failure.
Read article
Heart Failure Policy Network seeks information on multidisciplinary and integrated care
Heart Failure Policy Network seeks information on multidisciplinary and integrated care
19th February 2018
HFPN has launched a call for information on multidisciplinary and integrated heart failure care.
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The Heart Failure Policy Network is an independent, multidisciplinary platform made possible with financial support from AstraZeneca and Roche Diagnostics. The content produced by the Network is not biased toward any specific treatment or therapy. All outputs are guided and endorsed by the Network’s members. All members provide their time for free. The Network is hosted by The Health Policy Partnership .