Ensuring continuity across transitions

With Felix Lindberg, Karolinska Institute & Karolinska University Hospital, Stockholm - Sweden, Martha Kyriakou, European University of Cyprus, Nicosia - Cyprus and Maggie Simpson, University of Edinburgh, Edinburgh - UK.

In this episode, Felix Lindberg, Martha Kyriakou, and Maggie Simpson discuss multidisciplinary care in heart failure, exploring why HF complexity and multimorbidity make coordinated, team-based management essential.

They outline the key professional roles and how they can work together to support continuity across the HF trajectory, from diagnosis and optimisation, through decompensations, and transition to advanced therapies and palliative care.

The discussion also addresses real-world gaps in implementation, and considers how the expanding roles of nurses, pharmacists, and allied professionals, alongside emerging digital tools, may shape the future of multidisciplinary HF care.

• Examining the clinical role and educational preparation of heart failure nurses across Europe. A survey of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP) of the ESC. Hill et al. 2025. Eur J Heart Fail. DOI: 10.1002/ejhf.3519
• Multidisciplinary Care in Heart Failure Services. Sokos et al. 2023. J Card Fail. DOI: 10.1016/j.cardfail.2023.02.011
• The Core Curriculum for Cardiovascular Nurses and Allied Professionals. Neubeck et al. 2023. Eur J Cardiovasc Nurs. DOI: 10.1093/eurjcn/zvad035
• How to handle polypharmacy in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Stolfo et al. 2025. Eur J Heart Fail. DOI: 10.1002/ejhf.3642
• Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. Zheng et al. 2023. J Card Fail. DOI: 10.1016/j.cardfail.2023.03.01
• Nurse-led diuretic titration via a point-of-care urinary sodium sensor in patients with acute decompensated heart failure (EASY-HF): A single-centre, randomized, open-label study. Meekers et al. 2024. Eur J Heart Fail. DOI: 10.1002/ejhf.3429
• Heart failure disease management: a systematic review of effectiveness in heart failure with preserved ejection fraction. Kalogirou et al. 2020. ESC Heart Fail. DOI: 10.1002/ehf2.12559
• What Are Effective Program Characteristics of Self-Management Interventions in Patients With Heart Failure? An Individual Patient Data Meta-analysis. Jonkman et al. 2016. J Card Fail. DOI: 10.1016/j.cardfail.2016.06.422
• Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis. Van Spall et al. 2017. Eur J Heart Fail. DOI: 10.1002/ejhf.765

This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of an unrestricted financial support. The discussion has not been influenced in any way by its sponsor.