Planning according to the risk of clinical problems: low, intermediate or high (see table). The higher the risk, the sicker the patient and the more complex the management, the more frequent checks with the cardiologist.

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• Follow-up of the patient's clinical status.
• Support in pursuing optimal heart failure therapy.
• Biochemical monitoring.
• Support for the patient and his family.

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• Follow-up by a cardiologist specialized in heart failure and a heart failure nurse (read more).
• Optimal treatment of heart failure and co-morbidities.
• Heart failure nurse (read more).
• Telemonitoring (read more).

• Regular check-ups with the treating physicians, follow-up by a home nurse if necessary, telephone consultation with the heart failure nurse if necessary.
• Monitoring of own symptoms and parameters (weight, blood pressure, heart rate) (read more).
• Correct intake of prescribed medication (read more).
• Modified diet and relative fluid restriction (read more).
• Living correctly with heart failure (read more).

• Monitoring of parameters and symptoms.
• Medication follow-up.
• Lifestyle monitoring.
• Support for the patient and his family.
• Discussing possible advance care planning and therapy restrictions.

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• Screening for symptoms suspicious for heart failure or change in symptoms.
• Support for monitoring parameters: heart rate, blood pressure, weight.
• Delivery of prescribed medications with an overview of the complete medication list.
• Promoting adherence to therapy.
• Recognizing side effects of medications.
• Correct lifestyle advice.

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• Improvement of exercise capacity, either within the cardiac rehabilitation convention or outside the hospital.
• In addition, attention is also paid to:
  • Alarm symptoms.
  • Therapy adherence.
  • Parameters: weight, blood pressure, heart rate.
  • Healthy lifestyle and diet.
  • Self-reliance with referral for additional assistance if necessary.
  • Psychosocial support.

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• Education about relative salt and fluid restriction, healthy nutrition and any other dietary adjustments (low-potassium diet, dialysis diet, etc.).
• In addition, attention is also paid to:
  • Alarm symptoms.
  • Therapy adherence.
  • Parameters: weight, blood pressure, heart rate.
  • Healthy lifestyle and diet.
  • Self-reliance with referral for additional assistance if necessary.
  • Psychosocial support.

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• Support for:
  • The processing process and learning to deal with the disease (coping).
  • Learning techniques to cope with anxiety or stress.
  • Lifestyle changes, including quitting smoking or withdrawal from substance abuse.
  • Relational tensions or questions about sexuality and intimacy.
• In addition, attention is also paid to:
  • Alarm symptoms.
  • Therapy adherence.
  • Parameters: weight, blood pressure, heart rate.
  • Healthy lifestyle and diet.
  • Self-reliance with referral for additional assistance if necessary.

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• Fast diagnosis.
• Monitoring: heart rate, blood pressure, diuresis + determining weight.
• Prompt treatment: diuretics, oxygenation and/or hemodynamic stabilization if necessary.
• Admission preferably to the cardiology department, if necessary to the intensive care department

• Diagnostic assessment.
• Monitoring: heart rate, blood pressure, diuresis, weight.
• Full decongestion towards euvolemia – determining target weight.
• Rapid initiation and maximum titration of recommended heart failure therapy.
• Evaluation for possible indication for an implantable device: ICD, CRT,…
• Multidisciplinary follow-up:
  • Nurse (read more).
  • Heart failure nurse: education (read more).
  • Physiotherapy: cardiac rehabilitation (read more).
  • Dietician (read more).
  • Pharmacy (read more).
  • Social support (read more).
  • Psychological support (read more).
• If necessary, start-up telemonitoring.
• Planning intensive follow-up during the transition phase.

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• Monitoring of clinical condition, symptoms, heart rate, blood pressure, weight – early detection of cardiac decompensation, dehydration, hypotension,…
• If necessary, consult a heart failure nurse or cardiologist.
• Correct use of medication:
  • Avoiding Medicines to Avoid.
  • Continue heart failure therapy as much as possible.
  • After interruption of heart failure therapy: restart at a low dose as soon as possible and aim for uptitration to the chronic home dose.
• Multidisciplinary follow-up (see above)
  • Nurse.
  • Heart failure nurse: education.
  • Physiotherapy: cardiac rehabilitation.
  • Dietician.
  • Pharmacy.
  • Social support.
  • Psychological support.
• If necessary, follow-up planning with the cardiologist shortly after discharge.

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