Heart failure affects over 920,000 people in the UK, with around 200,000 new cases diagnosed annually. In Wales alone, over 46,000 people are diagnosed just by their GP, with many more going undiagnosed. 

This condition can have devastating effects, but it also causes immense strain to the NHS, accounting for 2% of all NHS hospital bed-days and is a leading cause of emergency admissions.  

With rates of diagnosis projected to nearly double by 2040, something has to be done and done quickly. 

STRONG HF

Safety, Tolerability and Efficacy of Rapid Up-titration of Guideline-directed Medical Therapies for Acute Heart Failure – or STRONG HF for short – is a landmark, multinational clinical trial transforming heart failure care.  

The trial, published in The Lancet, found that rapidly increasing heart failure medications to recommended doses within three weeks of hospital discharge – guided by blood biomarker testing – is safe and effective.   

Usually, medication is increased gradually over several months but the STRONG-HF approach safely compresses that timeline into just two weeks and has been shown to significantly reduce the risk of heart failure readmission and death in patients compared to usual care.  

For patients, this can mean fewer hospital stays and a faster return to normal life. 

In the UK, only three hospitals have begun implementing this approach, and Morriston Hospital in Swansea Bay is leading the way in Wales. 

A whole system approach

A major part of the STRONG HF pathway relies on a collaborative and whole-system approach to care, utilising different expertise of teams and providing points of contact for patients outside of hospital.  

Kerys Thomas, an Advanced Heart Failure Pharmacist in Swansea Bay, has witnessed firsthand how impactful this pathway can be.  

Speaking about the structure of STRONG HF, she explained, “I work in the Community Heart Failure Team which provides the interface between Primary and Secondary Care. Our Nurse and Pharmacist led Team works closely with the Inpatient Heart Failure Team, Consultant Cardiologists and Specialist Nurses, to support patients who have needed admission to hospital. We also work with GPs, practice nurses and pharmacists in Primary Care where the majority of heart failure patients are being cared for. 

What this structure has allowed, Kerys explains, is for teams to work in “multi-disciplinary ways”, sharing expertise and providing better care for patients that doesn’t always have to end in hospital admission. 

In particular, Kerys has noticed the benefits of nurses and pharmacists having a closer working relationship.  

“I’ve learned from the nursing perspective. They’ve learned from my perspective, and we find that our problem-solving is better because we work together to solve our problems,” she added, “Individually, we’re much less well equipped to do that.” 

It’s a sentiment echoed by Kerys’ colleagues on the STRONG HF team. Delyth Rucerean, Advanced Heart Failure Nurse Practitioner at Morriston, has also experienced a shift in how the teams work together.  

There is a strong culture of collaborative working,” she said. “Although we operate within different teams, we work closely together as one wider multidisciplinary team. This supports smoother transitions for patients moving between hospital and community care, and vice versa.“  

Delyth continued, “More recently, collaboration has expanded to include additional hospital teams involved in virtual wards and the same day assessment unit, enabling more coordinated and effective patient management.” 

Community care 

What has really shone through by adopting the STRONG HF model is the approach to community care, led by pharmacists and nurses. 

“What makes us very unique, putting heart failure to one side, is our community team,” Kerys said. 

The community heart failure team has transformed the care of patients with heart failure. By working with the GP, they can optimise heart failure therapy for patients and review recently discharged patients whose symptoms are getting worse (decompensated heart failure). This is already significantly improving patients’ symptoms and reducing hospital readmissions. 

Delyth explained, “Patients discharged with a diagnosis of decompensated heart failure are generally referred to the community team to support a smooth transition into community-based care. This joined up approach enables teams to work collaboratively across services, making a significant difference to continuity of care and overall patient management.” 

Kerys added, “We’re constantly triaging and listening to what clinicians need from primary and secondary care to try and assess how urgently we need to see a patient. So that layer, I think, is really needed.”  

“Specialist input is needed at those critical points, for example, post discharge, whilst optimised on heart failure medications or when symptoms are worsening. Once a patient is stabilised, then they are transitioned back to the care of their GP.  

“However, what you’ve got to remember is heart failure is a chronic disease with a poor prognosis, so patients inevitably, at some point, do deteriorate and they come back into our community heart failure service.” 

What is the impact on patients?  

Most importantly, STRONG HF and this collaborative approach to working are having incredible effects on patients diagnosed with heart failure.  

Dr Parin Shah, a cardiologist consultant on the STRONG HF team, explained: “These patients come in quite unwell, but within four weeks they’re back to work because of this intense optimisation of the heart failure medications 

“They’re getting very good quality care, quickly, and resuming their daily life within a few weeks.” 

He added: “From a service point of view, we are now liaising with the medical teams to discharge patients quicker. We know we can see them quickly, in one week, and get them optimised and stable rather than keeping them in hospital.” 

A model to be adopted?  

As services continue to evolve, STRONG-HF is showing how clinical research can do more than generate evidence; it can transform how care is delivered, giving more patients the chance to live well with heart failure. 

Kerys certainly believes this could be adopted elsewhere. She added, “It’s a model, I think that you can apply to all sorts of chronic conditions. It’s been a really good opportunity to work in a multi-disciplinary way.” 

Dr Parin also thinks it could open doors to collaboration with other health boards.  

“The health boards may have developed other pathways to optimise heart failure medication, so it is worth engaging with everyone,” he said. “The STRONG HF pathway is only suitable for 10% of patients with heart failure and liaising with other health boards to come up with strategies to optimise more patients rapidly will surely be beneficial. So, it’s definitely worth meeting with all the heart failure services to see what other structures they’ve made to help with that.” 

However, the reality remains that training, opportunities and funding are still huge barriers to healthcare.  

“There is a huge inequity in healthcare delivery with patients with heart failure, not just in Wales, but across the UK,” Delyth explained. “Access to specialist services, diagnostic investigations, and ongoing community support can vary considerably depending on where patients live and the resources available within local health boards and trusts. These inconsistencies can lead to differences in the timeliness, quality, and continuity of care that patients receive.” 

Delyth continued, “There are relatively few services across the UK that are able to provide rapid access diagnostic clinics alongside an intensive heart failure medication optimisation pathway, such as that used in STRONG-HF. The ability to deliver this type of model is heavily dependent on access to resources, workforce capacity, and appropriate staffing levels. As a result, implementation can vary considerably between services, contributing to wider inequalities in heart failure care provision.” 

“I believe every person should have equal access to the same standard of treatment and care. Unfortunately, from a national perspective, this is not consistently being achieved.  

“Variations in service provision, access to specialist support, and resource availability mean that patients’ experiences and outcomes can differ significantly depending on where they receive care,” she concluded.