Specialised Multidisciplinary Heart Failure Clinic in a Middle-income Country: A Single-centre Experience from 2016 to 2020

Heart failure (HF) is a progressive condition characterised by the structural and/or functional impairment of the heart, leading to inadequate blood supply to meet the metabolic needs of the body.¹ HF presents significant challenges globally, with its prevalence increasing rapidly in southeast Asia due to a rise in ageing populations and lifestyle factors, such as physical inactivity, obesity and smoking.² In Malaysia, HF has become a leading contributor to hospital admissions and a substantial economic burden on healthcare systems.³

Among the subtypes of HF, HF with reduced ejection fraction (HFrEF) carries a particularly poor prognosis, often marked by high rates of rehospitalisation and mortality.⁴ Medical therapies, such as angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), angiotensin receptor–neprilysin inhibitors (ARNI), β-blockers, mineralocorticoid receptor antagonists (MRA) and sodium–glucose cotransporter-2 inhibitors (SGLT2I), have shown efficacy in improving outcomes in these patients. As highlighted by Carrizales-Sepúlveda et al., combination use of these therapies significantly reduces all-cause mortality, cardiovascular (CV) mortality and HF-related admission.⁵ The STRONG-HF trial further demonstrated that intensive up-titration and structured follow-up can enhance these benefits. Despite strong evidence, real-world implementation in many Asian healthcare settings remains limited. Barriers such as insufficient access to specialised HF centres, geographical challenges in care delivery and lack of structured patient and caregiver education continue to hinder optimal pharmacological management.³ Addressing these issues is crucial to bridging the gap between clinical evidence and everyday practice.

Multidisciplinary HF clinics (MDHFCs) have emerged as a promising intervention model aimed at integrating evidence-based pharmacological treatments with holistic care. These clinics bring together a team of cardiologists, dieticians, psychologists, pharmacists and social workers to provide comprehensive support for HF patients, addressing both clinical and psychosocial needs.⁶ The effectiveness of MDHFCs in reducing hospitalisation, mortality and healthcare costs has been demonstrated in settings outside Malaysia, such as Taiwan and North America.⁷ However, their impact in a Malaysian healthcare setting remains underexplored. In Malaysia, ‘spoke-and-hub’ models are mainly adapted for CV care, where the HF cases are mostly handled by non-cardiac centres.⁸ Additionally, there are a lack of published local data on HF patient management outcomes and barriers to therapy, which limits opportunities for targeted improvement. Given the unique healthcare delivery structure, resource limitations and geographical disparities in Malaysia – particularly in regions such as Sarawak – there is an urgent need to evaluate the feasibility and effectiveness of MDHFCs within this context.^8,9

This study aims to evaluate the clinical outcomes and treatment pattern among patients with HFrEF managed at a single-centre MDHFC established at Sarawak Heart Center, Malaysia. Sarawak, located on the island of Borneo, is geographically vast and sparsely populated, with healthcare resources that are less concentrated than urban centres in Peninsular Malaysia.¹⁰ The clinic delivers integrated care encompassing pharmacological and device-based therapies, psychological support and lifestyle counselling, with the goal of improving patient outcomes and disease management.¹¹ The findings from this study are expected to provide insights into the feasibility and benefits of implementing MDHFC models in resource-limited healthcare settings.

Methods

Study Setting and Population

This clinical study was a single-centre, observational, retrospective study conducted in a MDHFC in the Sarawak Heart Centre, Malaysia. Patients were eligible for inclusion if they were aged ≥18 years, diagnosed with HFrEF and had their first clinic visit at the MDHFC between January 2016 and December 2020. Patients were excluded if they were pregnant, had a left ventricular (LV) ejection fraction (LVEF) >40% or were enrolled in other clinical trials. Included patients were followed up until December 2021 to assess 12-month clinical outcomes. The baseline index date was defined as the patient’s first visit to the MDHFC during the study enrolment period. The MDHFC-HF Study Protocol was approved by the Medical Research and Ethics Committee, Ministry of Health Malaysia and conducted according to the ethical standards in the International Conference on Harmonisation guidelines and the Declaration of Helsinki. Informed consent was waived, given that this was a retrospective chart review without extraction of identifiable patient data.

The Multidisciplinary Heart Failure Clinic Model in Sarawak Heart Centre

The Sarawak Heart Centre MDHFC was established in 2016 with the objective of providing comprehensive, coordinated outpatient care for patients with HF requiring guideline-directed medical therapy (GDMT) initiation and up-titration. Eligible patients were referred to the MDHFC after an initial consultation with the HF specialist.

The clinic operated on a once-a-week basis and was staffed by a dedicated team comprising an HF specialist, cardiology department physicians, specialised HF-trained nurses and HF pharmacists. Patients requiring additional interventions and subspeciality services, such as coronary angioplasty, were referred to the relevant specialty clinic for further management.

Upon enrolment, patients received structured counselling from HF nurses on non-pharmacotherapy, including dietary modifications, daily weight monitoring, fluid restrictions and recognition of HF symptoms and signs. The HF pharmacists conducted systemic reviews of pharmacotherapy to assess tolerability, identify adverse effects, evaluate adherence and provide recommendations to the HF specialists and doctors to facilitate optimal medication titration.

From 2016 to 2020, the MDHFC adhered to the treatment algorithm strategy for GDMT as outlined in 2016 European Society of Cardiology HF Guidelines.¹² During the initiation and up-titration phases, patients were reviewed every 2 weeks to enable timely dose adjustments and monitoring.¹² Once therapy was optimised and the patient’s clinical status stabilised, follow-up intervals were extended to every 2–3 months.¹²

Study Endpoints

The primary endpoints of this study were CV mortality, hospitalisation due to HF or ambulatory hospital visit for worsening HF at 12 months. We also recorded all-cause death, which included CV death and non-CV death. An ambulatory hospital visit for worsening HF was defined as any unplanned visit due to exacerbation of HF symptoms that required escalation of care, such as increased intravenous or oral diuretic use or treatment adjustment. Secondary endpoints included changes in New York Heart Association (NYHA) functional classification at 6 and 12 months; the proportion of patients prescribed with key GDMT between baseline and month 12. According to 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America Guideline for HF, class 1-recommended HF therapies (GDMT) refer to renin–angiotensin–aldosterone system inhibitors (RAASI), β-blockers, MRAs, SGLT2Is and diuretics as needed.¹³ Exploratory endpoints evaluated changes in echocardiographic parameters, such as LVEF, LV end-systolic volume (LVESV), LV end-diastolic volume (LVEDV), LV end-systolic diameter (LVESD) and LV end-diastolic diameter (LVEDD), from baseline to month 12.

Statistical Analyses

Statistical analyses were performed using Stata version 14 and SPSS version 22. Descriptive statistics were used to summarise demographic, clinical and treatment characteristics. Categorical variables were presented as frequencies and percentages, while continuous variables were summarised using means with standard deviations or medians with interquartile ranges, depending on the normality of distribution. The Shapiro–Wilk test was used to assess normality. For comparisons between groups, independent t-tests or Mann–Whitney U-tests were used for continuous variables, while χ² or Fisher’s exact tests were applied for categorical variables. Changes in echocardiographic parameters were analysed using analysis of covariance, adjusting for baseline values. No imputation was performed for missing data and a two-sided p<0.05 was considered statistically significant.

Results

In this MDHFC study, a total of 172 patients were included in the final analysis (Table 1 ). Of these, 140 patients (81.4%) were male. The mean age of patients recruited was 52.5 ± 14 years, the majority (41.9%) of whom were in the 18–49-year age range, highlighting a relatively young population. Supplementary Table 1 shows the detailed baseline data of patients recruited for MDHFC.

Supplementary Table 1 demonstrates the baseline clinical characteristics of patients recruited in MDHFC. The majority of patients (68.6%) were diagnosed with HF within the past year, while 31.4% were diagnosed within 3 years. Non-ischaemic heart disease was the predominant aetiology (59.5%). The most common clinical symptoms were shortness of breath (46.5%), pedal oedema (16.3%) and orthopnoea (15.1%), while prior coronary angiography was documented in 69.2% of patients and 28.5% had undergone percutaneous coronary intervention or coronary arterial bypass graft. Pre-existing comorbidities were prevalent in the cohort, with 54.1% having hypertension, followed by 40.7% with dyslipidaemia and 32.0% with diabetes. Clinical assessments revealed a mean systolic blood pressure of 127 mmHg (SD 19.6) and a mean diastolic blood pressure of 78.9 mmHg (SD 14.0). Renal function was generally preserved, with a mean estimated glomerular filtration rate of 79.5 ml/min/1.73 m²; however, a subset of patients had chronic kidney disease, with 80% classified as stage 1 or 2, 18.1% as stage 3 and 1.9% as stage 4 or 5. The mean LVEF was 24.8% (SD 7.4); 70.8% of patients had LVEF <30%. N-terminal pro-B-type natriuretic peptide levels were markedly elevated (median 1,200 pg/ml among patients with available data).

The primary outcomes, including CV mortality, HF hospitalisation, and ambulatory hospital visit for worsening HF events over 1 year, are presented in Table 2. Among the 172 patients, five (2.9%) died from a non-CV cause by the end of the follow-up period. Notably, no CV deaths were reported. Sixteen patients (9.5%) experienced at least one HF hospitalisation. Ambulatory worsening HF events were observed in 19 patients (11.3%); most experienced a single event (8.9%) and only a few experienced two or more events (2.4%)

At baseline, most patients were in NYHA class I (46.7%) or class II (47.9%), with only a small proportion in class III (5.3%) (Supplementary Table 1). By month 6, the proportion of patients in class I increased to 75%, with 25% in class II and none in class III or IV. At month 12, class I reached its highest proportion at 82%, followed by 18% in class II and 0.6% in class III (Supplementary Table 2). Table 3 summarises the changes in NYHA class of patients at month 6 and month 12 compared with baseline. By month 6, 38.4% showed improvement, 54.3% remained stable and 7.3% worsened. At month 12, 41.6% of patients showed improvement, 52.2% maintained and 6.2% worsened.

Of the HF medications prescribed at baseline (Table 4), a substantial proportion of patients were prescribed β-blockers 91.3%, ACEIs (66.9%) and MRAs (57.0%). Over the 12-month follow-up, a significant shift in prescribing patterns was observed. ARNI prescriptions increased from 15.1% at baseline to 34.8% at month 12, with a concurrent decline in ACEI use (48.2%). β-blocker use remained high (91.5%), while MRA prescriptions rose to 68.9%. SGLT2I use increased from 0.6% to 6.1%, reflecting evolving guideline adherence and availability. The proportion of patients receiving triple therapy (three class 1 recommended therapies) increased from 49.4% at baseline to 59.1% at month 12. Quadruple therapy, absent at baseline, was achieved in 1.8% of patients by month 12. Conversely, monotherapy and dual therapy regimens declined, indicating a trend toward more aggressive pharmacological management.

Marked improvements in cardiac function and structure were documented over the 12-month period (Table 5). Mean LVEF improved significantly from 24.5% to 39.1% (mean change 14.6%; p<0.001) indicating substantial recovery in systolic function. Significant reductions were observed in LVESV (from 136.4 ml to 94.9 ml) and LVEDV (from 180.0 to 150.8 ml), indicating reverse remodelling (p<0.001). Additionally, LV dimensions decreased significantly (LVESD −0.9 cm, LVEDD −0.4 cm; both p<0.001).

Discussion

This study described the impact of MDHFC in a resource-limited environment between 2016 and 2020 on the clinical status, functional capacity and HF pharmacotherapy prescription patterns in patients with HFrEF. Our study cohort demonstrated a low rate of 1-year CV death, HF hospitalisation and ambulatory worsening HF visits. Improvements were observed in NYHA functional class, HF drug up-titration and LVEF following 1 year of MDHFC care. In our cohort, the comparatively younger age distribution may reflect a higher prevalence of conventional CV risk factors leading to earlier ischaemic heart disease as well as a larger proportion of non-ischaemic cardiomyopathy, which has been observed to present at a younger age than ischaemic cardiomyopathy in large registry data.¹⁴

Potential Factors Leading to Better Heart Failure Clinical Outcomes in Multidisciplinary Heart Failure Clinics

The comparatively lower 1-year event rates observed in our cohort may be attributable to favourable baseline characteristics, including younger age, non-ischaemic aetiology and better renal function. These factors have been independently associated with improved HF outcomes.^15,16 Our findings align with previous studies from the pre-ARNI and pre-SGLT2I era, which demonstrated that MDHFCs were associated with reduced clinical events compared with usual care.¹⁷ Collectively, these observations support the on-going value of structured HF programmes in improving patient outcomes, even prior to the widespread adoption of newer pharmacological therapies.

Comparison with Regional Data on Heart Failure Clinic Care Clinical Outcomes

Different HF multidisciplinary management has been described in our region with various efficacy reported.¹⁸ Our study cohort exhibited lower clinical outcomes rates compared with the others.^{2,9,10,17–19} A larger proportion of ageing population and higher rate of renal impairments were among the key different patient characteristics that may explain the different rate of clinical outcomes in the other study.¹⁸ Our study findings align with a Malaysian study of multidisciplinary HF care conducted from 2017 to 2020 in which higher rates of GDMT, excluding SGLT2I, resulted in lower HF readmission rates and better NYHA functional class and HF pharmacotherapy prescription rates during follow up.⁹ Comparing our results to the MY-HF registry, which reported a higher 33.8% mortality rate and 58.7% readmission rate 1-year post-discharge, provides an intriguing juxtaposition.¹⁹ This difference can also be attributed to differences in the study population, where patients from the MY-HF registry were those admitted for decompensated HF, thus predisposing them to a higher risk for adverse outcomes. Overall, the MDHFC consistently resulted in higher prescription patterns of HF GDMT that may explain the better 1-year HF clinical outcomes.

Guideline-directed Medical Therapy Prescription Patterns in Multidisciplinary Heart Failure Clinics

To our knowledge, we first reported the HF GDMT prescription pattern and trend in a MDHFC comparing baseline, 6- and 12-month follow-ups prior to 2021 in Malaysia. Compared with prior similar MDHFC reports in our country, our findings agreed with the higher RAASI, ARNI and β-blocker prescription rates by 1-year, but not those of an MRA (spironolactone).^9,18 This could be explained by the nature of physician prescription patterns of HF GDMT, up-titrated and putting spironolactone at the third type of medication to be optimised after RAASIs and β-blockers. We also observed that most of our study cohort achieved the maximal tolerated dose of HF GDMTs without any further increment of prescription after 6 months. This observation was surprisingly consistent with recent observations, whereby the physician’s HF GDMT up-titration patterns also plateaued at 6 months after achieving patient’s maximal tolerated dosing.²⁰ This may imply the possible tolerability and feasibility to up-titrate HF GDMT in our population within 6 months using contemporary medication and guidelines, in the HF clinic setting.

The analysis of the GDMT prescribing patterns in this study revealed a notable trend towards increased use of the GDMTs, with increased uptake of triple and quadruple therapies. Drawing from multiple pivotal trials, guidelines unanimously recommend using the so-called four pillars of HF treatment, namely RAASI (ACEIs, ARBs), ARNI, β-blockers, MRAs and SGLT2Is.^5,21 We reported GDMT prescription by therapeutic class without dose stratification, as dosing was not prespecified during data collection and real-world achievement of guideline-recommended target doses is highly variable, with many patients receiving maximally tolerated doses.²² Nonetheless, reporting tolerated GDMT doses would provide important contextual insights, particularly in resource-limited settings, and should be incorporated in future studies to better inform clinical evaluation.

However, the usage of four GDMTs, even though significantly increased, remained scarce. The reason for this limited uptake can be attributed to the fact that SGLT2I had yet to be widely recommended as the fourth HF treatment pillar for most of this study’s duration.²³ Additionally, resource limitations in the region, particularly the high costs associated with ARNIs and SGLT2Is, have further hindered their widespread adoption, preventing the full implementation of the four-pillar strategy in many patients. This underscores the importance of addressing local barriers to access in order to optimise HF management in resource-limited settings.

Left Ventricular Remodelling in Heart Failure Patients Treated in Multidisciplinary Heart Failure Clinics

Numerous studies have shown that reverse remodelling is associated with better clinical outcomes, including lower rates of mortality and HF hospitalisation.^5,9,23 To our knowledge, this is the first report of LV remodelling changes beside LVEF echo parameters after a dedicated HF clinic intervention in our country. We observed a significant improvement in LVEF and reduction of LV chamber sizes after 12 months of HF treatment. These structural changes suggest favourable myocardial adaptation in response to optimised therapy. The results align with a previous study that indicated clinical improvement in symptoms and functional capabilities.⁹ The magnitude of LVEF increment also aligned with more recent HF clinic data that included a higher percentage of contemporary HF pharmacotherapy in Malaysia.^9,18 This may suggest that LV reverse remodelling by outpatient HF care goes beyond the up-titration of contemporary HF pharmacotherapy. We also observed a larger reduction in LV end-systolic size compared with diastolic measurements. This may suggest incomplete LV reverse remodelling despite LVEF and systolic improvement. Incomplete LV reverse remodelling is associated with a poorer clinical prognosis.²⁴ Therefore, in our study population, the role of further HF GDMT up-titration using contemporary HF drugs in the setting of favourable functional improvement and partial LV reverse remodelling remains to be elucidated. Our findings further suggest the need to perform echocardiography following up-titration of HF GDMT to assess residual incomplete reverse remodelling.

In summary, this study provides valuable insights into the potential benefit of an MDHFC in optimising HF management strategies and subsequently enhancing patient outcomes. A structured MDHFC in a resource-limiting setting may contribute to favourable 1-year clinical, functional and echocardiographic outcomes. Nonetheless, data generalisability remains a limitation, as the study is confined to a single centre, and the findings warrant corroboration in larger patient cohorts. Further studies on the effect of HF clinic care on more severe HF presentations, and in patients who are elderly or have renal impairment or arrhythmias are needed. With increasing disease prevalence, studies of the effect of structured HF clinics in non-cardiology centres and non-tertiary district healthcare centres are needed to fully ascertain the advantages of such clinics in socio–geographically challenged regions with larger proportions of lower-income populations. Overall, we believe the current findings in resource-limited settings will provide confidence and insights to further improve future HF care in our region.

While the observational nature of our study may introduce potential bias in certain outcomes, its strengths lie in the comprehensive evaluation of medication usage and detailed scrutiny of echocardiographic and clinical outcomes. Overall, this study aimed to show that, through the local MDHFC protocol, the involvement of pharmacy and nursing education within the clinic and personalised HF GDMT therapy according to patients’ clinical outcomes were achieved. The results highlight the potential for multidisciplinary HF care models to achieve better outcomes, even in a setting with limited resources.

Study Limitations

There are limitations to consider. The retrospective nature of the study introduces inherent bias, with findings based on a single-centre cohort, limiting generalisability. Additionally, outcomes beyond 12 months were not captured and quality-of-life metrics were not assessed. Given the geographical dispersion of the study population and the lack of a fully centralised electronic health record system, under-ascertainment of out-of-hospital events, loss to follow-up and missing outcome data may have contributed to the exceptionally low observed CV mortality at 12 months.

Conclusion

This study demonstrates that a structured MDHFC can significantly improve clinical outcomes, functional status, and pharmacological optimisation among patients with HFrEF in a middle-income country. The absence of CV mortality, low HF hospitalisation rate, and significant improvements in LVEF observed in this cohort highlight the effectiveness of coordinated, guideline-based care. These findings support the feasibility and effectiveness of MDHFCs in resource-limited settings and provide a basis for broader regional adoption to address the increasing burden of HF. Further research focusing on advanced HF, elderly patients and those with chronic kidney disease in this region is essential to evaluate and optimise the effectiveness of the current MDHFC model for our most vulnerable populations.

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