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Heart failure on the horizon: a call to action for policymakers in Spain


An expert multidisciplinary working group in Spain has contributed to the development of a forthcoming national cardiovascular health strategy, which will include a dedicated section on heart failure. To achieve this, the group developed a white paper to engage policymakers and make the case for multidisciplinary and integrated heart failure care. The paper outlines a best-practice care model and recommends quality indicators to measure performance.

The challenge

Heart failure has historically been excluded from healthcare strategies in Spain, despite affecting at least 5% of the country’s population.1 The syndrome is a leading cause of mortality and, for people aged 65 and over, the most common cause of hospitalisations.2-4

The inclusion of heart failure in a national strategy has been a long-standing goal for clinical leaders and patient advocates in Spain.5 Some regions, such as Extremadura, have developed integrated cardiovascular plans that prioritise heart failure,6 but many others have yet to follow suit.7 8

The response

In 2020, clinical leaders and patient advocates convened an expert national working group to develop a clear strategic vision for heart failure in Spain.9 The resulting white paper, Heart failure on the horizon 2025, makes detailed recommendations for regional and national policymakers to address common challenges in heart failure care. The document was developed with input from patient advocates, as well as healthcare professionals working in cardiology, internal medicine, primary and emergency care, and nursing.9

The white paper details a national multidisciplinary model for heart failure care that integrates services along the patient care journey.9 It includes best-practice recommendations for diagnosis, hospitalisation, discharge planning, early follow-up care and the division of clinical responsibilities. The document is based on The handbook of multidisciplinary and integrated heart failure care, a pan-European policy resource created by the Heart Failure Policy Network,10 but it was closely adapted to the regional and national context in Spain.5

The white paper presents a clear call to action for national and regional policymakers to:

  • develop a formal strategy for heart failure, with input from healthcare professionals and people living with the syndrome
  • invest in care beyond the acute hospital setting, by developing a specialist heart failure workforce and promoting formal accreditation for primary care professionals, internists and expert patients
  • ensure that national guidance and local care protocols meet quality standards, with the support of healthcare professionals, professional societies and patient organisations
  • prepare robust and public audits of performance using quality indicators.9

The working group recommends measuring and publishing data on process and outcome indicators, so centres can compare their services and identify opportunities for improvement.9 Indicators may vary across centres and regions, but the white paper recommends measuring performance in the following priority areas: patient health education, access to specialist care, use of guideline-recommended medications, community and outpatient care, discharge planning, hospital admissions and quality of life. According to experts involved in the white paper, performance data are essential to track local and regional progress against national policy recommendations.5

Heart failure on the horizon 2025 was launched during a webinar in November 2020.11 The event featured representatives from the white paper’s working group and Pilar Aparicio, National Director of Public Health, Quality and Innovation.

What has been achieved?

This is the first comprehensive white paper making the case for multidisciplinary and integrated heart failure care in Spain.9 Its recommendations were given close consideration by the Spanish Ministry of Health during the development of the forthcoming Strategy on cardiovascular health.5 The ministry has since confirmed that heart failure will feature as a priority in the strategy, alongside coronary heart disease, arrhythmias and heart valve disease.12 While its finalisation and launch may be delayed owing to the ongoing COVID-19 pandemic,13 the strategy represents a significant step forward for heart failure advocates in Spain.

Next steps

Some of the professional societies involved in the white paper have set up their own heart failure registries to monitor and compare performance across centres.14-17 Experts report that data from these registries will be used to monitor the implementation of the white paper’s recommendations at both the local and the regional level.5

Policy tips for heart failure advocates

  • Measure quality to guide and embed improvements in care: make deeper long-term commitments to secure progress and engage in organisational learning. Choose quality indicators that are relevant to local services and strategic priorities. Measure and compare performance to identify opportunities to improve care and patient outcomes.
  • Combine national engagement with a call for local plans: remember that national policy recommendations are not automatically implemented at the local level. Plans should consider local priorities, barriers and enablers. They should be developed with input from local decision-makers, people living with heart failure and healthcare professionals.
  • Build an alliance of professional societies and patient organisations: invite a wide range of perspectives from healthcare professionals and patient advocates to make a strong case that will appeal to policymakers.


Professor José Ramón González Juanatey (Professor of Cardiology and Director of the Cardiology and Intensive Care Department, University Hospital Santiago de Compostela):

  1. Sayago-Silva I, García-López F, Segovia-Cubero J. 2013. Epidemiology of heart failure in Spain over the last 20 years. Rev Esp Cardiol (Eng) 66(8): 649-56
  2. Rodríguez-Artalejo F, Banegas Banegas JR, Guallar-Castillón P. 2004. [Epidemiology of heart failure]. Rev Esp Cardiol 57(2): 163-70
  3. Instituto Nacional de Estadística. 2018. Defunciones según la causa de muerte: año 2017. Madrid: INE
  4. Instituto Nacional de Estadística. 2019. Defunciones según la causa de muerte: año 2018. Madrid: INE
  5. González Juanatey JR. 2021. Interview with Karolay Lorenty and Marissa Mes at The Health Policy Partnership [teleconference]. 23/07/21
  6. Junta de Extremadura. 2017. Plan Integral de Enfermedades Cardiovasculares de Extremadura. Mérida: Servicio Extremeño de Salud
  7. Junta de Castilla y León. 2005. Estrategia regional de salud cardiovascular en Castilla y León 2005-2007: enfermedad cerebrovascular y enfermedad isquémica del corazón. Valladolid: Calidad S
  8. Comunidad de Madrid. 2007. Plan de salud cardiovascular. Madrid: Salud Madrid
  9. González-Juanatey J, Comín-Colet J, García-Pinilla J, et al. 2020. Insuficiencia Cardíaca en el Horizonte 2025: cómo abordar uno de los principales retos sanitarios en España. Unpublished white paper: Comunicación CL
  10. Heart Failure Policy Network. 2018. The handbook of multidisciplinary and integrated heart failure care. London: HFPN
  11. Europa Press. Insuficiencia Cardíaca en el horizonte 2025: cómo abordar uno de los principales retos sanitarios. Available from: [Accessed 14/06/21]
  12. Gobierno de España. 2020. El Ministerio de Sanidad traslada a las CCAA el borrador de la Estrategia en Salud Cardiovascular del SNS. Available from: [Accessed 14/06/21]
  13. Heart Failure Policy Network. 2020. Heart failure policy and practice in Europe: Spain. London: HFPN
  14. Sociedad Española de Cardiología. Estudio RECALCAR. Available from: [Accessed 26/07/21]
  15. Sociedad Española de Medicina Interna. 2019. Registro RECALMIN: La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud. Madrid: SEMI
  16. Sociedad Española de Cardiología. Registro IC. Available from: [Accessed 26/07/21]
  17. Grupo de Insuficiencia Cardíaca y Fibrilación Auricular. Registro Nacional de Insuficienca Cardiaca: Información sobre el Registro. Available from: [Accessed 26/07/21]
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 .