Aufbau und Organisation von Herzinsuffizienz-Netzwerken (HF‑NETs) und Herzinsuffizienz-Einheiten („Heart Failure Units“, HFUs) zur Optimierung der Behandlung der akuten und chronischen Herzinsuffizienz

[Healthcare quality and safety in left ventricular assist device therapy from the patient perspective: A qualitative study on relevant aspects of care]

INTRODUCTION

Implantation of a left ventricular assist device (LVAD) requires extensive aftercare. It is largely unclear how aftercare should be designed from the patients' perspective. Implications can be developed based on an examination of the healthcare context. Its main components are mapped on five tiers in the Human Factors of Home Health Care Model by Henriksen, Joseph, and Zayas-Caban (2009). Using this model, the present study explores the patient perspective on the context of healthcare after an LVAD implantation.

METHODS

We employed a qualitative cross-sectional study, in which LVAD patients participated in semi-structured interviews. The transcribed interviews were analyzed using content analysis. First, relevant meaning units were identified and deductively categorized into the model. Then, categories of care-related aspects were developed inductively within each of the model tiers.

RESULTS

We interviewed 18 patients aged 33 to 78 years who had been living with the LVAD between a few weeks and more than 10 years. Twenty-eight categories related to care aspects were developed within the model tiers: 3 categories on patient characteristics (e.g., self-management skills), 3 on caregiver characteristics (e.g., professionalism), 11 healthcare-related tasks and requirements (e.g., wound management), 8 on factors of the physical environment (e.g., controllability), medical devices and technologies (e.g., carrying systems for external components), and cultural, social and community environment (e.g., interaction with peers), as well as 3 on external environmental factors (e.g., healthcare infrastructure).

DISCUSSION

The present study represents the first investigation focusing on aspects of the healthcare context influencing healthcare quality and safety from the perspective of LVAD patients in Germany. LVAD aftercare covers a broad and complex range of tasks. For this, patients, caregivers and healthcare professionals need specific knowledge, which is lacking in various respects. In the first place, this is compensated by the patients' own initiative and the personal care provided by the VAD outpatient clinics.

CONCLUSION

Three key recommendations to optimize aftercare from the patient perspective are derived: Patients would benefit from a more flexible and decentralized aftercare concept, to which telemedicine could contribute. LVAD-specific expertise among general healthcare providers is perceived as insufficient by patients and could be strengthened through training and counseling services. The broad scope of tasks and the high level of responsibilities in LVAD aftercare pose challenges for patients and their families, which could be addressed through continuous information and training programs.

Determining Contextual Factors for a Heart Failure Self-Care Intervention: A Consensus Delphi Study (ACHIEVE)

There is a rising recognition of the crucial role self-care plays in managing heart failure (HF). Yet patients often have difficulties implementing ongoing self-care recommendations into their daily lives. There is also recognition of the importance of theory for successful intervention design, and understanding of key factors for implementation so interventions fit a given context. Local key stakeholders can provide valuable insights to help understand relevant context-specific factors for intervention implementation. This study sought to engage stakeholders to explore and determine relevant contextual factors needed to design and facilitate successful implementation of an HF self-care intervention in the German health care system. A ranking-type Delphi approach was used to establish consensus from stakeholders (i.e., clinicians, patients, policymakers/potential funders) regarding eight factors (content, interventionist, target group, location, mode of delivery, intensity, duration, and format) to adequately define the components and implementation strategy of the intervention. Seventeen participants were invited to participate in the first Delphi round. A response rate of 94% (16/17) was achieved and maintained for all three Delphi rounds. Stakeholder consensus determined that nurses specializing in HF are the most appropriate interventionists, target groups should include patients and carers, and the intervention should occur in an outpatient HF clinic, be a mixture of group and individual training sessions, and last for 30 minutes. Sessions should take place more frequently in the beginning and less often over time. Local stakeholders can help determine contextual factors that must be taken into account for successful delivery of an intervention. This enables the intervention to be developed and applied based on these factors, to make it suitable for the target context and to enhance participation to achieve the desired outcomes.

Clinical experience with medical hypnosis as an adjunctive therapy in heart surgery

Heart surgery patients are at high risk for psychological trauma and comorbid psychological disorders. Depression, anxiety, and post-traumatic stress disorders in this patient group are predictors of outcomes after cardiac surgery. Medical hypnosis is effective for non-pharmacologic prevention and treatment of psychological disorders and has been associated with improved health-related quality of life and better cardiovascular outcomes. This contribution makes note of evidence of the effectiveness of medical hypnosis in a discussion of the clinical experience with specific hypnotherapeutic tools and interventions from the perspective of the mental health team in one large cardiac center in Germany. Based on our experience, we encourage heart centers to educate their heart surgery care teams about the core concepts of medical hypnosis and to make hypnotherapeutic techniques available as an adjunctive therapy.

Structural components for the development of a heart failure network

Diagnosis and treatment of heart failure (HF) is challenging, and development of specialized HF networks is mandatory to warrant broad access to guideline directed therapies for patients. Numerous national cardiovascular societies recommend a three-level association of health care providers. This comprises tertiary academic centres, specialized HF clinics and specialized general cardiologists to cover the large spectrum of HF severity and entities. Although this idea of a multi-level care is widely accepted, optimal approach to build and implement a HF network service needs further definition. The core principle is that of network healthcare facilities that also consider regional peculiarities and that implements academic standards, quality indicators (QIs), interdisciplinarity and reimbursement strategies. These determinants of trans-sectoral healthcare need to be embedded in a network that provides sustainability and that incorporates QIs to objectify the efficacy of specific measures. The basis of a HF-network should be a certification system of the respective national HF association to warrant guideline standards and to prevent development of regional hierarchies or dependencies between members. This nationwide framework needs to be complemented by a federal system of regional networks, which also takes local demands into account. These regional units should incorporate digital communication and interaction pathways, structured educational programmes, certified telehealth concepts and follow-up algorithms to meet the requirements of sustainability and efficacy. We here summarize different components of HF networks and introduce the structure and development philosophy of the RUHR-HF-network that constitutes the first certified HF-clinics-network in the Ruhr area-the largest metropolitan area in Germany.

Multidisziplinärer Teamansatz in der Versorgung von Patienten mit Herzinsuffizienz

Die Versorgung von Patienten mit Herzinsuffizienz durch multidisziplinäre Teams wird von (inter-)nationalen Leitlinien seit Jahren mit höchstem Nachdruck empfohlen, ist aber bislang nicht hinreichend implementiert. Im deutschen Gesundheitssystem gibt es bisher nur für den hochspezialisierten Bereich konkrete Vorgaben zur Zusammensetzung dieser Teams (z. B. Heart Team oder Heart Failure Team), während sie für den ambulanten Sektor fehlen. Zur Verbesserung der Versorgungssituation herzinsuffizienter Patienten konzipierten DGK und die DGTHG im Jahr 2016 die Einführung von zertifizierten Herzinsuffizienz-Netzwerken. Diese fokussierten allerdings auf die kardiologisch-kardiochirurgisch unterstützte intersektorale Betreuung. Um die Primärversorger adäquat in das Netzwerk mit einzubinden, bedarf es einer Erweiterung dieses Konzepts und einer regional angepassten, individuellen Ausgestaltung. Eine gemeinsame, barrierefrei bedienbare Kommunikationsplattform in Form einer elektronischen Fallakte ist dabei eine zentrale Voraussetzung für eine moderne, erfolgreiche Interaktion. Die aktualisierte Fassung des Disease-Management-Programms Herzinsuffizienz (DMP-HI) könnte die strukturierte Interaktion gezielt stärken, indem sie diese zur Bedingung macht und dafür Anreize schafft.

Pulmonary artery sensor system pressure monitoring to improve heart failure outcomes (PASSPORT-HF): rationale and design of the PASSPORT-HF multicenter randomized clinical trial

Background

Remote monitoring of patients with New York Heart Association (NYHA) functional class III heart failure (HF) using daily transmission of pulmonary artery (PA) pressure values has shown a reduction in HF-related hospitalizations and improved quality of life in patients.

Objectives

PASSPORT-HF is a prospective, randomized, open, multicenter trial evaluating the effects of a hemodynamic-guided, HF nurse-led care approach using the CardioMEMS™ HF-System on clinical end points.

Methods and results

The PASSPORT-HF trial has been commissioned by the German Federal Joint Committee (G-BA) to ascertain the efficacy of PA pressure-guided remote care in the German health-care system. PASSPORT-HF includes adult HF patients in NYHA functional class III, who experienced an HF-related hospitalization within the last 12 months. Patients with reduced ejection fraction must be on stable guideline-directed pharmacotherapy. Patients will be randomized centrally 1:1 to implantation of a CardioMEMS™ sensor or control. All patients will receive post-discharge support facilitated by trained HF nurses providing structured telephone-based care. The trial will enroll 554 patients at about 50 study sites. The primary end point is a composite of the number of unplanned HF-related rehospitalizations or all-cause death after 12 months of follow-up, and all events will be adjudicated centrally. Secondary end points include device/system-related complications, components of the primary end point, days alive and out of hospital, disease-specific and generic health-related quality of life including their sub-scales, and laboratory parameters of organ damage and disease progression.

Conclusions

PASSPORT-HF will define the efficacy of implementing hemodynamic monitoring as a novel disease management tool in routine outpatient care.

Trial registration

ClinicalTrials.gov; NCT04398654, 13-MAY-2020.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-01987-3.

From guideline to daily practice: Implementation of ESC-guidelines considering multidisciplinary and non-pharmacological care in heart failure in three ESC member states, a case study

INTRODUCTION

To alleviate the burden of Heart Failure (HF), the European Society of cardiology developed guidelines (ESC-guidelines) to optimise HF-diagnosis and treatment. These guidelines state that optimal HF-care is organised in a multidisciplinary programme in which pharmacological and non-pharmacological treatment is offered. Research has proven that multidisciplinary programmes and effective self-care behaviour significantly reduce HF-mortality and (re)hospitalisation, yet little is known about implementation of these ESC-guidelines. Therefore, the INTERACT study investigated current HF-care processes and guideline adherence in three North-West European regions: Maastricht (the Netherlands), Aachen (Germany) and Noorder-Kempen (Belgium).

METHODS

A case-study approach was adopted to study local implementation of ESC-guidelines considering non-pharmacological- and multidisciplinary care. National guidelines and local protocols were collected and studied to investigate the level of agreement with and implementation of ESC-guidelines. A matrix was developed to analyse the content of national and local guidelines and protocols in terms of non-pharmacological and multidisciplinary care.

RESULTS

All national organisations promote ESC guidelines, and some developed additional national guidelines. In region A, B and C patients receive multidisciplinary care in hospital based HF-outpatient clinics. Moreover, region B and C patients benefit from either structural (region B) or project based (region C) integrated care, in which specialist- and primary care work together to provide seamless care for HF-patients. However, in region A this seamless integrated care remains to be implemented.

CONCLUSION

Although ESC-guidelines recommend clearly considering Multidisciplinary- and non-pharmacological care implementation may differ between regions.

Psychological burden and coping in destination therapy patients with a left ventricular assist device: a qualitative content analysis

BACKGROUND

Due to an increasing prevalence of heart failure and persistent shortage of donor hearts, the number of left ventricular assist device (LVAD) implantations is growing. As more patients live with LVADs for prolonged periods of time, psychosocial outcomes are becoming more relevant. This particularly applies to destination therapy (DT) patients, who live with the LVAD for the rest of their lives.

METHODS

We used a cross-sectional qualitative design to explore psychological burden, coping strategies and resources from the perspective of DT patients. Data was collected via semi-structured in-depth interviews with 18 patients who lived with the LVAD for 3 months to over 10 years. These were analyzed using an inductive content analysis. Due to the COVID-19 pandemic, changes to the recruitment strategy and data collection strategies of the original study protocol were applied. Patients and clinicians were involved throughout the research process to ensure validity of the results and implications.

RESULTS

We synthesized 10 psychosocial, health, and treatment-related burdens, identified 15 problem- and emotion-focused coping strategies and 5 personal and environmental resources patients used to cope with the burden.

CONCLUSIONS

The findings provide deeper insights into the complex and specific situation of LVAD patients to better address the patient situation in health care and promote positive psychosocial outcomes. So far, health care practice and quality vary significantly between clinics due to individual treatment protocols. Our results highlight the need to improve medical and psychosocial care. Overarching care concepts may be developed based on the implications.

[Early Integration of Palliative Care - A Definition for Daily Practice]

Early Integration of Palliative Care - A Definition for Daily Practice Abstract. The integration of palliative care into the treatment of patients with chronically progressive or incurable diseases can be useful early in the course of the disease. The integrative approach of disease-specific and palliative therapy can improve the quality of life of those affected. Different aspects, such as symptom relief, decision making, advance planning, network building or support for relatives can be addressed from the bio-psycho-social-spiritual perspective. The article gives an overview of the most important aspects of early integration of palliative care and shows, also with actual case reports, how integration can be managed in practice.

[Heart failure care in a digitalized future : A discourse on resource-sparing structures and self-determined patients]

Digital health solutions, applications of artificial intelligence (AI) and new technologies, such as cardiac magnetic resonance imaging and cardiac human genetics are currently being validated in cardiac healthcare pathways. They show promising approaches for improving existing healthcare structures in the future by strengthening the focus on predictive, preventive and personalized medicine. In addition, the accompanying use of digital health applications will become increasingly more important in the future healthcare, especially in patients with chronic diseases. In this article, the authors describe a case of chronic heart failure (HF) as an example to provide an overview of how digitalized healthcare can be efficiently designed across sectors and disciplines in the future. Moreover, the importance of a self-determined patient management for the treatment process itself is underlined. Since HF is frequently accompanied by various comorbidities during the course of the disease that are often recognized only after a delay, the necessity for a timely simultaneous and preventive treatment of multiple comorbidities in cardiovascular diseases is emphasized. Against this background the currently separately applied disease management programs (DMP) are critically questioned. The development of a holistic DMP encompassing all indications for the treatment of chronic diseases may pave the way to a more efficient medical care system.

Herzinsuffizienz-Netzwerke – Struktur, Organisation, Ziele

Die zunehmende Inzidenz der Herzinsuffizienz, als häufigste zur Krankenhausaufnahme führende Gesundheitsstörung, bedarf in einer demografisch alternden Gesellschaft eines optimierten und ressourcensparenden Diagnostik- und Therapieplans in hierfür spezialisierten sektorenübergreifenden Herzinsuffizienz-Netzwerken (HF-NET), wo nicht nur die häufigen Komorbiditäten und Komplikationen, sondern auch die zunehmende Anzahl zur Verfügung stehender medikamentöser und interventioneller Therapiemöglichkeiten einen interdisziplinären und intersektoralen Versorgungsansatz bei limitierten Ressourcen ermöglicht. Insbesondere vor dem Hintergrund, dass der Verlauf der Herzinsuffizienz durch rezidivierende Dekompensation (meist Volumenretention etc.) charakterisiert ist, ermöglichen die im HF-NET optimierten Versorgungs- und Kommunikationsstrukturen der bei Herzinsuffizienz betroffenen Leistungserbringer, drohende Dekompensationen frühzeitiger und prognostisch relevant zu erkennen und zu behandeln.

Herzinsuffizienzbehandlung in Integrierten Versorgungsmodellen nach § 140 SGB V

Deutschlandweit werden über 20.000 Patienten in integrierten Herzinsuffizienz-Versorgungsmodellen betreut (Bundesverband Niedergelassener Kardiologen, persönliche Kommunikation, 16. Juli 2020). Durch eine damit einhergehende, leitliniengerechte Pharmakotherapie und regelmäßige Kontrolluntersuchungen lässt sich die Lebensqualität von herzinsuffizienten Patienten deutlich verbessern. Darüber hinaus lassen sich Krankenhauseinweisungen und daraus resultierend Kosten für die Krankenversicherungen minimieren. Eine enge Kooperation (in einem Netzwerk) zwischen Klinikkardiologen, niedergelassenen Kardiologen und Hausärzten ermöglicht eine optimale Herzinsuffizienz-Behandlung in allen Herzinsuffizienz-Schweregraden. Integrierte Versorgungmodelle wie CorBene oder KardioExpert tragen dazu bei, neben einer optimalen Patientenbetreuung, wissenschaftliche Auswertungen vorzunehmen und harte Endpunkte wie Re-Hospitalisierung oder kardiovaskuläre Mortalität zu reduzieren. Das hier vorgestellte KHAD-Modell (Kölner Herzen Atmen durch") ist ein integriertes Versorgungsmodell in dem die aktuellen Leitlinienempfehlungen zur poststationären Versorgung von Herzinsuffizienzpatienten in der Region Köln umgesetzt werden sollen. Fast allen Krankenkassen unterstützen das Modell. Es nehmen alle Kölner Krankenhäuser und einige der niedergelassenen Kölner Kardiologen teil, um eine optimale Herzinsuffizienz-Versorgung gewährleisten zu können. Solche Modelle für eine Herzinsuffizienz-Betreuung könnten in allen deutschen Großstädten praktiziert werden. Zum Wohle der Patienten, zur Einsparung von Potenzialen bei den Krankenkassen, für eine angemessene Honorierung der behandelnden Ärzte und zur Entlastung der Krankenhäuser – ein Gewinn für unsere Patienten und alle Beteiligten im Gesundheitssystem.

Hospitalizations for heart failure: still major differences between East and West Germany 30 years after reunification

Aims

Heart failure (HF) is the most common primary inpatient diagnosis in Germany. We examined temporal trends of HF hospitalization within Germany focusing on regional differences.

Methods and results

We analysed aggregated data of more than 320 million hospitalizations in Germany from 2000 to 2017. Temporal trends of HF‐related parameters were analysed, focusing on regional differences between the federal states. The absolute number of HF‐related hospitalizations throughout Germany increased continuously and almost doubled (from 239 694 to 464 724 cases, +94%) with the relative increase being higher in East Germany compared with West Germany (119% vs. 88%). These regional differences persisted after age standardization with 609 and 490 cases per 100 000 population, respectively. The length of stay decreased continuously across Germany (from 14.3 to 10.2 days; −29%), while the total number of HF‐related hospital days increased by 51% in East Germany and 35% in West Germany. In 2017, HF remained the leading cause of in‐hospital death (8.9% of all cases), with a markedly higher rate in East vs. West Germany (65 vs. 43 deaths per 100 000 population).

Conclusions

Heart failure remains the most common cause of hospitalization and in‐hospital death throughout Germany. The increase in HF‐related morbidity and mortality was much higher in East Germany compared with West Germany during the observation period. A more detailed understanding of these striking disparities 30 years after the German reunification requires further investigations. There is an urgent need for action with regard to stronger control of risk factors and improvement of both chronic HF management and healthcare structures.

[Care of patients with chronic heart failure: an interdisciplinary challenge]

The diverse manifestations of heart failure led to complex treatment guidelines and care scenarios and therefore always require an integrated, multidisciplinary care approach. Patients with chronic heart failure suffer from a large number of cardiac and noncardiac comorbidities. For example, iron deficiency leads to decreased performance and exertional dyspnea and should be diagnosed. Psychological screening questionnaires should be used for the early detection of psychological comorbidities.ARNI and SGLT-inhibitors expand the pharmacotherapeutic possibilities and gain in importance. The constant development of diagnostic possibilities and therapeutic options must be implemented consistently into the care continuum in order to have a lasting effect. The challenge of interdisciplinary coordination can be significantly reduced through jointly agreed process logs (e. g. within the framework of integrated supply contracts or a Heart Failure Unit Network).

The Treatment of Heart Failure with Reduced Ejection Fraction

BACKGROUND

Chronic congestive heart failure is a common condition that, if untreated, markedly impairs the quality of life and is associated with a high risk of recurrent hospitalization and death.

METHODS

This review is based on articles retrieved by a selective search in PubMed, as well as on relevant guidelines.

RESULTS

Evidence-based treatment options are available only for congestive heart failure with a low ejection fraction. Pharma - cotherapy is based on neurohumoral inhibition of the renin-angiotensin-aldosterone system and the adrenergic system. The prognosis of patients with this condition has been further improved recently through the introduction of combined angiotensin receptor antagonists and neprilysin inhibitors. Modern implantable devices are a further component of treatment. Implantable defibrillators and special pacemakers for cardiac resynchronization are well established; the utility of alternative devices (baroreflex modulation or cardiac contractility modulation) needs to be investigated in further studies. It was recently shown that the catheter-based treatment of secondary mitral regurgitation with a MitraClip improves the outcome of selected patients.

CONCLUSION

The treatment of chronic systolic heart failure as recommended in the relevant guidelines, with drugs and implanted devices if indicated, can significantly improve the clinical outcome.

[Diagnostics and treatment of chronic heart failure : Update 2020]

Heart failure is a systemic disease. As populations are aging worldwide, the prevalence and importance of comorbidities as major determinants of heart failure symptoms, disease progression and prognosis are increasing. Since the last version of the European Society of Cardiology guidelines for the diagnosis and treatment of heart failure was published in 2016, promising novel pharmacotherapies for chronic heart failure and its comorbidities and new device-based treatment and monitoring options have become available; however, the broad range of therapeutic options as well as the diagnostic and therapeutic implications of comorbidities render the treatment of heart failure increasingly more complex. This review aims to provide practical guidance for a rational up-to-date approach to the evidence-based management of heart failure.

Physiological monitoring in the complex multimorbid heart failure patient - Conclusions

Comorbidities are increasingly recognized as crucial components of the heart failure syndrome. Main specific challenges are polypharmacy, poor adherence to treatments, psychological aspects, and the need of monitoring after discharge. The chronic multimorbid patient therefore represents a specific heart failure phenotype that needs an appropriate and continuous management over time. This supplement issue covers the key points of a series of meeting coordinated by the Heart Failure Association of the European Society of Cardiology (ESC), that have discussed the issues surrounding the effective monitoring of our ever more complex and multimorbid heart failure patients. Here, we present an overview of the complex issues from a healthcare delivery perspective.

[Heart failure networks and centers : What does everyday life look like?]

The German Cardiac Society (DGK) and the German Society for Thoracic and Cardiovascular Surgery (DGTHG) jointly advocated the initiation and certification of heart failure (HF) networks in a position statement in 2016. In these networks, supraregional HF centers cooperate with specialized regional HF clinics and registered cardiologists to improve intersectoral treatment of patients with HF. So far predominantly supraregional HF centers have achieved certification but more recently regional clinics as well as registered cardiologists have applied for certification, now enabling the comprehensive establishment of HF networks. In this article the background, the current situation and the future perspectives of HF networks are assessed and approaches for better networking are discussed.

[Certification : Pro: indispensable component of quality]

Certification is a critical component of quality assurance in medicine. From the certification of individual persons, through units and up to whole hospitals, certification stimulates testing and optimization of treatment processes, thereby improving the quality of care. Minimum case numbers needed to acquire a certificate are an important and objective attribute of quality. Advantages of certification include an improved treatment of patients, structured training of new employees and enhanced cost efficiency.

Curriculum heart failure : Task force curriculum heart failure of the working group on heart failure of the Austrian Cardiological Society

It is well recognized that organized management of heart failure patients, including care by heart failure specialists, improves outcomes of these patients. In response to this, the Heart Failure Association of the European Society of Cardiology proposed a basic framework of a heart failure curriculum, which became a blueprint for training programs across Europe. The present curriculum for heart failure was well coordinated with the version issued by the German Society for Cardiology in order to achieve good comparability. Training in this Austrian curriculum takes two years, during which the predominant activity focuses on the care of patients with heart failure. The first year includes general (basic) training, while in the second year special modules (advanced chronic and acute heart failure with specific treatment, device treatment, interventional heart failure treatment, outpatient care or rehabilitation, heart failure diagnostics) must be chosen that impart in-depth knowledge, experience and/or skills. Of the five offered modules two must be completed for 6 months each. At least one specialist in internal medicine and cardiology with the additional qualification of heart failure must act as a supervisor at the training center. A certified Heart Failure Unit or a comparable structure should be available at the training center and integrated into the clinical routine of the cardiology department. Applications for recognition of curricular achievements in order to obtain the additional qualification “heart failure specialist” shall be evaluated by a dedicated committee of the nucleus of the Heart Failure Working Group of the Austrian Cardiological Society. The candidate will receive recognition of the additional qualification in heart failure, issued by the Austrian Cardiological Society.

[Certification in cardiology : Contra: The concept should be improved]

Increasing complexity and new highly differentiated therapeutic procedures in cardiology result in a need for additional training beyond cardiology board certification. The German Cardiac Society therefore developed a variety of certifications of educational curricula and definition of specialized centers. Standardization and structuring in education and patient treatment, as defined by certifications may be helpful; however, introduction of certification can have serious consequences for hospital structure, the side effects of which may impair quality of treatment for individual patients. The current article discusses these issues against the background of the following questions: how is quality defined? How do certifications interfere with patient care on a nationwide level, how do they influence responsibilities and teamwork? Are there conflicts of interests by designing certifications and how good are the organizational structures? Finally, suggestions are made on what has to be considered when designing certifications. Certifications should acknowledge all cardiologists, irrespective of their position in the level of care. There should be a coherent unified concept synchronizing all certifications and administration needs to be transparent and well structured.

[Circulatory failure : Out- and inpatient management]

Circulatory insufficiency is often understood as symptomatic hypotension due to various causes. The clinical result of circulatory dysregulation is arterial hypotension. The manifestation of hypotension is often divided into chronic and acute forms. Chronic hypotension can be distinguished etiopathogenetically into primary and secondary hypotension. Acute hypotension is usually equated to circulatory shock. While patients with chronic hypotension should be seen primarily by their general practitioner, patients with acute hypotension and a frequently severe clinical manifestation should be evaluated in the emergency department or, if there is a specific cause, directly in the acute clinic. Standardization of diagnostic and therapeutic pathways in both out- and inpatient care-not only for the management of circulatory weakness-would be an improvement not only in regards to patient care, but also with respect to healthcare economics.