World Heart Federation Roadmap for Heart Failure

The authors report no relationships that could be construed as a conflict of interest. Supplementary data associated with this article can be found, in the online version, at https://doi. org/10.1016/j.gheart.2019. 07.004. From the *National Institute of Health and Medical Research, Center for Clinical Multidisciplinary João Pedro Ferreira*, Sarah Krausy, Sharon Mitchellz, Pablo Perelx, Daniel Piñeirojj, Ovidiu Chioncel{, Roberto Colque, Rudolf A. de Boer**, Juan Esteban Gomez-Mesayy, Hugo Grancellizz, Carolyn S. P. Lamxx, Antoni Martinez-Rubiojjjj, John J. V. McMurray{{, Alexandre Mebazaa##,***,yyy, Gurusher Panjrathzzz, Ileana L. Piñaxxx,jjjjjj, Mahmoud Sani{{{,###, David Sim****, Mary Walshyyyy, Clyde Yancyzzzz, Faiez Zannadxxxx, Karen Sliwajjjjjjjj


METHODOLOGY AND SELECTION AND THE EXPERT WRITING GROUP
To ensure a best practice approach and a consensus document (Figure 2), the WHF Heart Failure Roadmap was developed through review of published guidelines and research papers, in consultation with a dedicated writing group composed of experts in heart failure management and health systems research. WHF regional Members were invited to nominate an expert to the writing group to ensure that the content of the Roadmap has true global representation.
An extensive review of the applicability and acceptability of the outlined roadblocks and proposed solutions was conducted. A survey was sent to all WHF Members using snowball sampling to widen the consultation, not only to regional members, but also to national representatives. A total of 146 responses was collated through this process, offering feedback on the proposed Ideal Heart Failure Continuum of Care Pathway ( Figure 3) and the presented roadblocks and solutions ( Table 1). The results were analyzed, open comments were reviewed and consolidated, and the findings were incorporated into this document.
The development of the Heart Failure Roadmap forms part of a larger global project that seeks to create living documents that inform initiatives in response to the global The authors report no relationships that could be construed as a conflict of interest. Supplementary data associated with this article can be found, in the online version, at https://doi. org/10.1016/j.gheart.2019. 07.004.
needs of patients with CVD. Using publication as a first step in organizing and establishing consensus on the heart failure "care gap," the WHF Heart Failure Roadmap can be used as a springboard to initiate a call for action and prescribe measurable steps toward a common goal, at national and international levels.

HEART FAILURE DEFINITION
"Heart failure is a complex clinical syndrome caused by any cardiac structural and/or functional abnormality that results in impairment of ventricular filling or ejection of blood" [9].
Heart failure can present acutely or as a progressive disease characterized by worsening shortness of breath, coughing or wheezing, tiredness and fatigue, fluid retention with swelling of the legs and/or abdomen, and/or reduced ability to do physically demanding tasks or exercise [8].
Central to diagnosing heart failure is the demonstration of underlying structural and/or functional cardiac abnormalities. Accepted definitions used to categorize heart failure include [8,9]: heart failure with reduced ejection fraction ([HFrEF]; left ventricular ejection fraction [LVEF] <40%); heart failure with preserved ejection fraction (LVEF 50%); and heart failure with midrange ejection fraction (LVEF 40% to 49%). Patients with heart failure with preserved ejection fraction often have history of hypertension and/or atrial fibrillation [10], whereas patients with HFrEF are often younger and may have a history of ischemic heart disease or cardiomyopathy (Online Tables 1 and 2

RELEVANCE OF HEART FAILURE TO THE GLOBAL BURDEN OF CVD
It has been estimated that there are approximately 26 million cases of heart failure worldwide [15]. This does not account for the cases of heart failure that are undiagnosed or misdiagnosed and, therefore, a true estimate of the global burden heart failure remains unclear [16]. Mortality rates for heart failure patients remain high with 17% to 45% of deaths occurring within 1 year of diagnosis-with the majority of deaths occurring within 5 years of admission [8].
Of the annual 17.9 million cardiovascular-related deaths worldwide, 80% occur within LMIC [15,17e19], a trend replicated in heart failure where mortality rates are higher in these regions [18e21]. Despite this, our understanding of heart failure is largely based on studies undertaken in high-income countries and building a picture that truly reflects the epidemiology of heart failure across all regions, especially LMIC where mortality risk and specific death causes from heart failure are still largely unexplained [17], remains a challenge.
The few data available clearly show that the prognosis in heart failure varies according to geographic area [8].
One-year death rates in patients with heart failure remain high in LMIC, reaching 34% in Africa, 23% in India, 15% in South East Asia, 9% in South America, and 7% in China [17]. Disparities in patient outcomes may be explained by differences in the severity of heart failure at presentation, available therapies, resources, and health care systems [20]. However, further analysis of specific causes of death and related comorbidities is needed to improve patient care.
Numerous causes of heart failure have been described including infectious diseases (Chagas and rheumatic heart disease) and cardiac conditions (hypertension, heart muscle disease, coronary heart disease, valve disease, congenital heart disease, pericardial disease, cor pulmonale, and rhythm disorders) [8]. Figure 4 highlights the most common causes contributing to heart failure by region [17,22,23]. It is evident from this regional map that ischemic heart disease and hypertension are the most common causes of heart failure globally.

SUMMARY OF HEART FAILURE MANAGEMENT GUIDELINES
To prevent the development of the heart failure syndrome, one needs to address its most common causes (e.g., hypertension, ischemic heart disease, rheumatic heart disease) and, ideally, should consider screening for asymptomatic left ventricular (LV) dysfunction in high-risk individuals (Online Table 2) [8,11e15].
The goals of heart failure management are to 1) treat the underlying cause; 2) improve clinical status, functional capacity, and quality of life; 3) prevent hospitalizations; and 4) reduce mortality. Drug therapy for the treatment of the clinical syndrome of heart failure includes diuretic agents to relieve the signs and symptoms of congestion and disease-modifying therapies, such as angiotensinconverting enzyme inhibitors (or angiotensin receptor blockers), beta-blockers, mineralocorticoid receptor antagonists, angiotensin-receptor-neprilysin inhibitor, and ivabradine. These drugs have been shown to reduce hospitalization and improve survival when used as specified by the guidelines [8,9]. Additional therapies, such as hydralazine-isosorbide dinitrate and digoxin, may be used in symptomatic patients with HFrEF. Device therapy (e.g., cardiac resynchronization therapy, implantable cardioverter-defibrillators, LV assist devices) and heart transplantation may be indicated in selected patients with advanced disease. Table 2 represents a summary of heart failure guidelines from European Society of Cardiology and American College of Cardiology/American Heart Association.

CARE GAP AND THE IDEAL HEALTH CARE JOURNEY FOR HEART FAILURE
The "care gap" refers to the difference between optimal, evidence-based, guideline-recommended care and what is delivered in practice. Although the care gap may be considered larger in LMIC, disparities have been reported in screening, diagnosis, treatment, and monitoring of patients across all income settings. The ideal pathway of care (referred to in this Roadmap as the "continuum of care pathway") was developed using an evidence-informed approach and considers the entire journey of the patient and a best-practice treatment approach.

The Ideal Journey for Heart Failure Patients
Each step along the heart failure journey is important, with many shared determining factors, regardless of local and regional differences in resources or health service delivery. The continuum of care focuses on a common pathway for heart failure patients ( Figure 3) and includes identifying individuals at risk, diagnosing heart failure, outlining necessary investigations, treatment initiation, and followup. The aim of this section is not to reiterate published guidelines, but rather to investigate best-practice approaches for each step in the care pathway and to identify important stakeholders that may strengthen health care delivery to patients with heart failure.
Heart Failure Prevention. General Population: There is considerable evidence that the onset of heart failure may be delayed or prevented through interventions aimed at modifying risk factors, as outlined in previously published WHF Roadmaps (Figure 1) [1e6]. Heart failure prevention strategies ( Figure 3) are not dissimilar to those across the spectrum of CVD, and it is, therefore, appropriate to dedicate time and effort on key primary prevention strategies such as smoking cessation [21,24], alcohol reduction or cessation [25], exercise training [26], as well as secondary prevention measures, as described in previous Roadmaps.
Opportunistic Screening and Diagnosis. Individual at Risk: Screening plays an essential role in the early diagnosis of heart disease and is useful in identifying those at higher risk of developing heart failure. Screening needs to be adapted according to affordability and availability of a health care system and the different underlying causes per region. Globally underlying causes of heart failure include hypertension (the most common cause of heart failure), myocardial infarction, diabetes, and valvular heart disease, including rheumatic heart disease and cardiomyopathies [27e29]. In addition to those with traditional CVD risk factors, individuals at increased risk of developing heart failure include peripartum women, those who have received chemotherapy, individuals with systemic inflammatory conditions, and those with a positive family history of heart disease or sudden cardiac death (Figure 3).
Regional and national guidelines in acute and chronic heart failure offer quality recommendations in the diagnosis and management of heart failure, yet for a number of reasons including poor adherence and health economic factors, these recommendations lead to a gap between best-practice recommendations and implementation [8]. Careful history taking, systematic clinical examination, and appropriate investigations are necessary to follow a bestpractice approach [9]. A woman's pregnancy history is an integral part of her assessment and pregnancy-related diagnoses, such as pre-eclampsia, eclampsia, or gestational diabetes, could signal premature development of CVD with a 4-fold risk of incident heart failure [30].
Despite resource limitations, a diagnosis of heart failure can be made at the primary care level. Careful assessment of symptoms (breathlessness, ankle swelling, and fatigue) and signs (elevated jugular venous pressure, pulmonary crackles, and peripheral edema) can be helpful, but may not be sufficient to confirm a diagnosis of heart failure [8]. The electrocardiogram (ECG) is widely recognized as having an essential role in the diagnosis of underlying cardiac disease [8,9], and, whereas an abnormal ECG has low specificity [31], heart failure is highly unlikely to be present if the ECG is completely normal [32]. Basic investigations, including biomarkers (B-type natriuretic peptide, N-terminal proeB-type natriuretic peptide), ECG, and focused point-of-care echocardiogram, are useful tools for screening high-risk individuals and confirming a diagnosis of heart failure and, ideally should be accessible at primary care facilities. Future artificial intelligence-enabled "smart" tools for both ECG [33] and echocardiography [34] may further enhance early detection of heart failure at the community level. Patients diagnosed with heart failure usually require referral to higher levels of care for more comprehensive clinical evaluation and investigation, particularly those with advanced disease, to confirm and manage the underlying cardiac condition. A table of diagnostic investigations can be found in Online Treatment: Initiation of Guideline-Based Therapy and/or Treatment of the Specific Cause. New-onset heart failure requires urgent initiation of therapy [35]. Heart failure management requires the use of: 1) a guideline-based approach with pharmacological and/or nonpharmacological therapies [9]; 2) a patient-centered approach promoting shared decision making with patients [36]; and 3) patient education to improve treatment adherence [37]. Regardless of whether a patient presents with asymptomatic LV dysfunction or overt heart failure, careful consideration of their history and examination is required to implement an appropriate guideline-based treatment plan [8] (Figure 3, Table 2, Online Table 3).
Heart failure is a clinical syndrome, and a comprehensive diagnosis is dependent on the demonstration of an underlying cardiac cause to ensure appropriate and specific treatment [8]. The diagnostic work-up of the underlying cardiac cause should therefore be conducted in conjunction with the therapeutic management of the heart failure syndrome. Furthermore, to provide holistic care to heart failure patients, other medical and social cofactors, such as concomitant comorbidities, contraception, vaccination, gRECS j GLOBAL HEART, VOL. 14, NO. 3, 2019 nutrition, work, driving, and transportation, need to be addressed simultaneously.
Monitoring and Follow-Up: Stable Patient Follow-Up as per Guidelines. Monitoring and follow-up are an essential part in the overall management of heart failure and are discussed in detail in the published guidelines (see Figure 3). The primary goal in monitoring and follow-up is to detect possible decompensation (worsening heart failure) and prescribe appropriate therapy as early as possible. This may be achieved through consultation in a heath care facility, via telephone or, more recently, through the use of mobile health (mHealth) packages [38].

PERSPECTIVES ON HEART FAILURE
Heart failure is a chronic, progressive condition with a poor prognosis if left untreated [39]. For the purpose of this Roadmap, barriers and possible solutions to care will be presented from the perspective of: 1) patients, families, communities, patient organizations, and civil society; 2) health care professionals, including clinicians and allied health professionals; and 3) decision makers, nonprofit organizations, government officials, and leaders in heart failure.
Heart failure can be a life-changing and debilitating disease [40]. The diagnosis may lead to inaccurate assumptions and misconceptions about the condition [41e43]. The gradual decline of patients with heart failure, often interrupted by episodes of acute deterioration, recurrent hospitalizations, or sudden unexpected death can have devastating effects on both patients and their families [44].
"A lot of people with heart failure think that's the end of their lives, as soon as they get a diagnosis. I did at first, I thought, that's it." "With heart failure it's very unknown, people just don't know what it is" [45].
Differences in perspectives between patients and health care professionals may affect patient care. One study reported that patients and caregivers believed that "trouble breathing" was a reason for hospitalization, whereas clinicians identified nonadherence to diet and medications, progression of disease, and various socioeconomic factors, such as a lack of social support and access to medications, as reasons for hospital admissions. The investigators suggest that health care workers may not recognize some of the biggest challenges facing heart failure patients [46]. The Handbook of Multidisciplinary and Integrated Heart Failure Care supports a patient-centeredecare approach that is flexible and adaptable to the patients' needs [47] ( Figure 5). The purpose of this Roadmap is to propose strategies and interventions to improve the care of patients with heart failure across all settings. A unified approach to care requires an improved understanding and appreciation of the daily challenges faced by patients and caregivers, dedicated funding, and well-designed health systems that meet the specific needs of these patients.    failure. Information gathered from this survey has enabled us to focus on high priority areas and to include specific examples of interventions and evidence in practice.
Note: Within this section not all roadblocks and solutions are discussed. The focus has been targeted on the areas that received highest levels of agreement within the WHF survey results from April 2019, with support from reported roadblocks from published findings.

Screening and Early Diagnosis
Setting: General Public and Civil Society.
A "low level of understanding among patients with heart failure" was the highest ranked perceived roadblock in early diagnosis; almost 48% of survey respondents cited this as the highest, or second highest, priority area in the prevention of heart failure in the general population. In addition, a well-noted barrier in both the published reports and the WHF survey, was "a low level of awareness and knowledge on symptoms of heart failure among health care professionals, particularly at primary care level" [42], and "the general public" (SHAPE [Study Group on HF Awareness and Perception in Europe] study) [48,49]. More recent studies reiterate that awareness of heart failure has not improved in the past 10 years, despite a rising incidence of heart failure worldwide, with a reported lifetime risk of 1 in 5 [50]. Low awareness of the symptoms associated with heart failure in communities may delay the presentation of patients to a health care facility, potentially postponing diagnosis and treatment. Heart failure has and continues to be fraught with misunderstandings, inaccuracies, and misconceptions [43].
Possible solutions to overcome low awareness of heart failure requires local, national, regional, and international efforts to improve the public's understanding of heart failure using all possible communication channels and communitybased healthy living programs. The website www. heartfailurematters.org is a useful and easy-to-access source of information for patients, families, and caregivers, and is translated into 9 languages [51]. European Heart Failure Awareness Week, Heart Failure Awareness Week-"Do Your Part, Know Your Heart" Campaign (Heart Failure Society of America) and "Keep it Pumping" Campaign (Cardiology Society of India) are examples of programs designed to create awareness among patients and caregivers and gather the support of national societies. Whereas evidence is lacking in the effectiveness of awareness campaigns in heart failure specifically, research in other disease areas indicates that increased awareness directly correlates with earlier detection and diagnosis [52,53]. The key action area is to create open, direct, and innovative communication opportunities that all people involved in the global fight against heart failure can actively support.

Screening
Screening patients for asymptomatic LV systolic dysfunction, risk of heart failure, or minimal symptoms such as   mild dyspnea is not straightforward and there is no single investigation that can conclusively confirm a diagnosis of heart failure [9]. Evidence continues to emerge for implementing standardized screening for heart failure [54]. Screening of high-risk patients using algorithms such as the SCORE (Systematic COronary Risk Evaluation) Risk Charts or the Framingham risk calculator have reported mixed success [55]. Targeting high-risk populations require effective strategies for identifying at-risk patients within clinical practice [55]. Whereas current guidelines underline the importance of natriuretic peptides for the purpose of early diagnosis of heart failure, evidence is building in support of their use in prevention and screening in high-risk individuals [54e56]. Examples of the use of natriuretic peptides in practice is further discussed within the diagnostic section of this document. For an integrated approach to improving awareness of heart failure, see Table 3 [54,57,58].

Diagnosis
Setting: Primary Care, Community Care, Specialist Centers.
Making an accurate comprehensive diagnosis requires a range of diagnostic tools and information, in conjunction with clinical judgment and expert knowledge. Whereas the diagnosis of patients presenting with the classic symptoms of heart failure can be relatively straightforward [59], it can be more difficult in the early stages of disease when symptoms and signs may be less obvious, particularly if there is limited availability of the necessary investigative modalities [32]. A number of studies have sought to investigate clinically relevant diagnostic research at the primary care level in the detection of heart failure [60e62] subsequently confirmed following investigations by a cardiologist at a specialist clinic [61].
An Integrated Approach to Address Roadblocks to Diagnosis, Examples in Practice. Limited investigations at primary care level: The role of primary care in the detection and diagnosis of heart failure is critical [63]. Disparities in the diagnosis and management of heart  [9,65,66]. Improving access to diagnostic tests: Late presentation of heart failure patients (due to poor socioeconomic status, low levels of education or rural isolation) was the highest ranked roadblock related to diagnosis from the WHF survey, with 89% of survey respondents in agreement. Another frequently cited roadblock was access to specialist clinics for diagnosis and management of heart disease. Echocardiography is the single most important diagnostic imaging technique [67], yet 10% to 25% of patients admitted to hospitals in Europe and the United States with a primary diagnosis of heart failure do not undergo echocardiography [68]. Overcoming this barrier requires: 1) the improvement of service delivery models; and 2) upskilling and task shifting of specific skills of health care workers along the care pathway.
For early detection and diagnosis, there is a need to commission cost-effective testing opportunities, most notably for echocardiography [8] and natriuretic peptides [69] to facilitate the diagnosis of heart failure. Both these recommendations are set forth in the 2016 Focus on Heart Failure report [70]. It is well recognized that CVD is common in LMIC, and 44% of patients with newly diagnosed CVD present with heart failure [71]. In Africa, a large percentage of the population simply do not have access to the necessary care, with limited access to doctors, particularly specialists residing in capital cities, and have challenges associated with transportation, particularly in rural areas [72].
The following example tells a compelling story of an effort, supported of the Rwandan Ministry of Health, to reach a large at-risk population in Rwanda. With an aim of decentralizing services for heart failure, integrated nurseled and physician-supervised clinics were set up in 2 rural public-sector district hospitals. A strategy to disseminate the use of portable echocardiography and simplified algorithms for diagnosis was established. Nurses were trained to perform and interpret limited echocardiographic studies using visual qualitative inspection to make a preliminary diagnosis, with a confirmatory diagnosis made following referral to a cardiologist. This simplified approach to early diagnosis in a resource-limited setting is just an example of how to provide care in difficult-to-reach populations [73]. Access to specialist care at a district level can also be achieved by arranging rotational specialist visits and may help to address a number of reported roadblocks along this care pathway.
For an integrated approach to improve access to diagnostic tests, see Table 4 [74,75].

Treatment
Setting: Specialist centers, primary care, community care centers, home care visits.
The aim of heart failure treatment is to improve life expectancy and quality of life [76]. Within the pathway of care, initiation of treatment and therapeutic strategies for heart failure patients varies considerably depending on the cause of heart failure. Patients with asymptomatic LV systolic dysfunction may follow a treatment pathway that differs considerably from the approach for patients with overt heart failure following a cardiac event [9]. Determining the primary diagnosis can be particularly challenging in patients with multiple cardiovascular and noncardiovascular comorbidities, and diagnostic uncertainty may sometimes delay the implementation of appropriate treatment strategies. Treatment pathways may vary depending on disease severity, the underlying cause, and the classification (HFrEF, heart failure with midrange ejection fraction, or heart failure with preserved ejection fraction) of heart failure and may involve nonpharmacological, pharmacological, and invasive (percutaneous or surgical) interventions [8]. In Disease Control Priorities, Third edition, chapter 10, "Heart Failure," offers a summary report of heart failure interventions applicable across geographic settings [77].
Medication may help to slow disease progression, improve symptoms, and decrease hospital readmissions in heart failure patients [76,78], yet adherence to medication remains among the greatest perceived barriers to care among health care professionals and researchers in cardiovascular health [79e81]. This perception was reflected in the WHF survey to Members with "adherence on medication" reported as the greatest barrier (over 90% agreement) to best-practice treatment. Additional barriers include a low level of knowledge among patients about the medication they are prescribed [82], and prescribed treatment may not be in alignment with published guidelines and evidence-based therapy [83].
An Integrated Approach to Address Roadblocks to Treatment, Examples in Practice. There are a number of trials and studies that support the positive effect of patient interventions pre-discharge and at 60 and 90 days following hospital admission, particularly with regard to medication adherence (IMPACT-HF [Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure] trial [84]; BRING-UP [Betablockers in Patients With Congestive Heart Failure: Guided Use in Clinical Practice] [85]; OPTIMIZE-HF [Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure] [86]). To design targeted interventions, better understanding about the factors that lead to poor adherence to medications from the patient and gRECS j GLOBAL HEART, VOL. 14, NO. 3, 2019 community perspective is required. Studies for other chronic conditions, such as the antiretroviral qualitative study in human immunodeficiency virus (HIV) conducted in South Africa [87], provide valuable insights into population-specific challenges related to adherence.
The economic burden of heart failure, particularly the cost related to hospitalizations, has generated research interest into the various models of care that may improve outcomes, particularly rehospitalization [88]. Several studies have successfully shown the importance of community-based programs in improving patient adherence to medication [80,89] and reducing hospitalization [90]. In an effort to improve medication adherence for antiretroviral therapy in HIV, Antiretroviral Therapy Clinics in South Africa have introduced a "dual solution approach." This approach focuses on pairing up "community-based patient follow-up programs and patient education" initiatives (discussed in more detail in the Monitoring section) on key messages and specific information considered essential for patients to manage their disease.
For other possible solution focused on treatment, see Table 5 [89,91e94].

Monitoring
Setting: Primary care, community care centers, home care visits, specialist centers.
Heart failure monitoring refers to the follow-up of patients to detect and treat the signs and symptoms of heart failure to prevent disease progression. Recurrent hospitalizations are common in heart failure [8,9] and may be a consequence of disease progression, suboptimal treatment, a lack of psychosocial support, poor diet and/ or impaired capacity for overall self-care [92,95]. A collaborative multidisciplinary approach is often required to reduce hospital readmissions and improve quality of life [96,97]. A lack of knowledge of the purpose of medications and how to self-manage symptoms of deterioration [98,99] was the highest reported roadblock to best patient care. Furthermore, a limited understanding of heart failure among patients and caregivers is Lack of awareness and lack of knowledge of heart failure Support patient organizations to communicate with the general public, patients, and caregivers by providing the information they need to empower patients to make informed decisions on seeking treatment, identifying risks, and playing a role in the management of their own health. Patients, carers, families, patient organizations, and civil society Harness advocacy as a powerful tool to bring together those with a common cause to raise the profile of heart failure on national agendas, thereby raising awareness of heart failure among patients, but also among decision and policy makers.

Leaders in cardiovascular health
Strengthen leadership among policy and decision makers, so they better recognize and understand the challenges of heart failure care. Policy continues to fail in making the essential link between scientific evidence to set policy decisions.

Leaders in cardiovascular health
Drive action among leaders to reduce inequalities across geographic settings. Strengthen communication across sectors to ensure alignment in strategies from national to urban and rural settings with a view to putting heart failure on national priority agendas. Health care workers (primary and secondary care setting) Work collaboratively with patients to reduce their risk of developing heart failure and help them to manage their health. Build evidence on the use of natriuretic peptide-based screening and collaborative care. Evidence in Practice PAHO Rallies New Partners for Chronic Disease Prevention: the Pan American Health Organisation (PAHO) brought together health advocates across the continent to become partners in a public-private effort to fight NCD focusing on key actions areas including changing policy, reducing risk factors, and improving treatment. "Policy makers' perceptions of the high burden of heart disease in rural Australia" [57]: a paper highlighting inequality in resourcing, and political pressure and education as key constraints to evidence-based policy in rural communities. Pan African Ministries of health meeting on hypertension: an example of a regional meeting involving ministries of health, education, agriculture, transport and finance, among other stakeholders, to support a move from science into policy and to leverage support for key recommendations in addressing hypertension in Africa [58]. STOP-HF (Natriuretic peptide-based screening and collaborative care for heart failure) randomized study: the first reported example to show a reduction in newly diagnosed heart failure, suggesting that a targeted strategy for the prevention of heart failure using natriuretic peptides and collaborative care in a community population may be effective [54].
jg RECS reflected by reports of poor correlation between symptoms, such as breathlessness, and the disease itself [44,45,98].
An Integrated Approach to Address Roadblocks to Monitoring, Examples in Practice. Patient education: Educating patients is central to patient care and has been shown to improve patient outcomes and quality of life [99,100]. There are numerous approaches to patient education, and consideration of different learning styles in the dissemination of key messages is essential when choosing an approach. The use of blended learning and a multimethod approach tailored to patient needs may be required [101,102]. In addition, follow-up programs must consider the most appropriate intervention for each patient according to their specific needs [103]. The Lack of access to primary care clinics for diagnosis Implement patient communication and education initiatives that are essential to deliver best-practice care to heart failure patients. Early detection and diagnosis are uniformly linked to awareness and prevention. Recognizing the signs and symptoms of heart failure, understanding specific risk factors, and communicating with health care professionals is an essential step.

Leaders in cardiovascular health
Lack of knowledge among the general public to recognize symptoms and seek medical attention Improve access for patients to overcome social inequalities and late presentation due to poor education or rural isolation. Invest in leadership and agency in health system planning to set up decentralized heart failure clinics linked to centralized advanced treatment centers. Health care workers (primary and secondary care setting) Support patients with low health literacy using e-health in a collaborative approach to care. Appoint experts to lead heart failure care and advocacy across settings and disciplines. This is an evidence-based consensus policy recommendation that focuses on an integrated approach to care to develop protocols, training and local auditing [74].

Evidence in Practice
Decentralized heart failure centers established linked to a centralized care unit across South India to improve access for patients: this intervention has yet to be published but was shared with WHF during the survey process. HeLP-GP (Health eLiteracy for prevention in General Practice) intervention from Australia [75]: this study investigates the impact and outputs of a mobile health application for adults with lower levels of health literacy in the primary care setting.
WHF, World Heart Federation. Equip patient education initiatives with behavioral supports to improve medication adherence. Implement patient education programs and interventions to support treatment adherence.

Leaders in cardiovascular health
The treatment of patients with a polypill that is affordable [91] is well reported to improve adherence. This solution could well be adapted for heart failure [92]. Policy interventions that reduce direct costs to patients for prescriptions through reduced medication copayments or improved prescription drug coverage have been shown to improve adherence to medication. Health care workers (primary and secondary care setting) Take a collaborative approach to care that has been shown to systematically improve adherence to medications.

Evidence in Practice
World Health Organization and Sri Lanka study: underlines effectiveness and safety of treating patients with a polypill [93]. Copayment reductions: generate greater medication adherence in targeted patients 2010 [94]. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial 2007 [89]. gRECS j GLOBAL HEART, VOL. 14, NO. 3, 2019 mode of delivery of education may vary depending on the setting, the health care team, and how civil society organizations deliver key disease messages. Educational frameworks and design methodology are essential considerations in implementing effective education programs [104]. Disease management: A recent Cochrane review evaluated the role of disease management for patients with heart failure. Disease management refers to a model of care that emphasizes proactive and preventive care in hospitals, clinics, or homes, rather than crisis intervention as per the traditional model. These models are typically run by nurses and/or multidisciplinary teams. Data from 47 randomized clinical studies (10,869 participants) suggested that case management and multidisciplinary interventions may reduce all-cause mortality; however, there is limited evidence that disease management decreases hospital readmissions or heart failureerelated deaths. Although promising, the overall quality of evidence is low and most of the studies related to disease management have been conducted in high-income countries [105].
Telemonitoring: Another recent Cochrane review evaluated the role of noninvasive home telemonitoring and telephonic support for people with heart failure [106]. The review identified 41 randomized controlled trials: 25 studies (9,332 participants) evaluating telephonic support, and 18 evaluating telemonitoring (3,860 participants). Only 2 studies evaluated both interventions and most of the studies were conducted in high-income countries. There was moderate evidence that home telemonitoring or telephonic support reduces all-cause mortality and hospitalization due to heart failure.
Whereas interventions such as education, multidisciplinary teams, disease management, and technology for monitoring are promising, their implementation and sustainability in real-world settings remain a challenge. Further implementation research is needed to fully understand how these complex interventions affect patient care and outcomes, particularly in LMIC where there is a paucity of data.
For an integrated approach to improving patient monitoring and follow-up, see Table 6 [106e108].

ADAPTING TO NATIONAL ROADMAPS-FROM PRESCRIBED RECOMMENDATIONS TO PRACTICE IMPLEMENTATION
This Roadmap describes an ideal continuum of care pathway for heart failure, explores the roadblocks along this pathway, and considers potential solutions based on available research and examples in practice. To move from prescribed global recommendations to local and national implementation, a number of specific actions are required to plan, design, and implement change. Previous Roadmaps have outlined steps for adapting suggested frameworks at the national level: multisectorial coalition; situational analyses to consider the national needs, the health care system, and policy environment; policy dialogues to identify and discuss specific barriers and potential strategies; and plan of action to design and implement specific interventions [4]. These steps provide guidance in the development of a call for action for improving heart failure care and reducing the burden of this rising epidemic. This process is well described in previous Roadmap recommendations [1e6].
The WHF implementation toolkit ( Figure 6) offers a step-by-step approach to specific action areas and highlights the importance of an integration across multiple care settings. To move from a global Roadmap initiative to a national Improve health literacy among patients through targeted programs.
Education for self-care through follow-up programs has been shown to have a positive impact on reduced mortality and reduced hospitalization.

Leaders in cardiovascular health
Lack of collaboration across care settings Implement education and capacity-building programs for health care professionals at primary and community care level as a first-line approach to improving monitoring and follow-up of patients. Health care workers (primary and secondary care setting) Implement interventions and follow-up treatment programs, including mHealth and e-health interventions. Where this may be difficult to achieve telephone support services have also shown better self-care behavior. Evidence in Practice CardioMEMS heart failure system (Abbott, Abbott Park, Illinois), which measures the pulmonary artery pressure and heart rate through an implanted sensor: daily blood pressure readings transmit data to either a primary care or specialist doctor supporting continuous monitoring [107]. "Effect of a medication-taking behavior feedback, theory-based intervention on outcomes in patients with heart failure" 2011 [108]. DIAL (Randomised trial of telephone intervention in chronic heart failure) trial, which tested the effectiveness of a telephone-based intervention covering more than 50 centers and 1,500 patients: highlighted the positive impact of this follow-up program to reduce heart failure hospital admissions by 30% [106].
jg RECS call for action to service implementation, strong leadership and integration between sectors is required, including national ministries of health, education, labor, finance, and transport; health care system decision makers; health care professionals; and representatives from industry, patients, carers, and civil society. Bringing key leaders and stakeholders together for national Roundtable discussions to consider a unified heart failure agenda based on national and local needs is considered a necessary first step. WHF continues to support national and regional societies and Members to raise the profile of heart failure as a priority area, by facilitating national Roundtable stakeholder discussions, national scorecards, and by creating a global network of research, through initiatives such as the WHF Emerging Leaders program, in addition to providing supporting toolkits for implementation and guidance in key actions areas such as advocacy. All WHF initiatives are aimed at supporting national efforts to reduce the growing burden of heart failure.

FINAL CONSIDERATIONS FOR THE FUTURE OF HEART FAILURE PATIENTS
With an estimated 26 million individuals living with heart failure globally [16], the burden of heart failure is felt at every level of health care: for systems and health care workers confronted by greater numbers of ill patients; and for health economies faced with increasing costs associated with heart failure. Social and geographic inequalities add to this burden for those most vulnerable. Despite challenges in the delivery of high-quality care to heart failure patients, there are many examples of successful interventions that have been implemented in various socioeconomic settings that may pave the way for a brighter future for heart failure patients.
This WHF Heart Failure Roadmap offers an outline of an ideal continuum of care pathway for heart failure that is relevant across all countries and regions. Specific roadblocks may differ depending on local context. By raising awareness of heart failure among health care professionals and key stakeholders, addressing the inequities of care to patients with heart failure, highlighting common challenges in the delivery of care globally, and bridging the care gap between knowledge and implementation, this Heart Failure Roadmap provides a platform on which to build services that prioritize patients and improve outcomes for heart failure patients.