Dicussion
This observational study presents the clinical characteristics of patients admitted to two large local hospitals in Norway with acute heart failure. Only 81 out of 136 screened patients with heart failure met the inclusion criteria. Preterminal illness, a high degree of frailty and in-hospital death were the main reasons for exclusion. The participants had a median age of 79 years (10 % were < 70 years old) and multimorbidity, and 8 out of 10 had previously been admitted to hospital for heart failure. Self-care and health literacy levels of patients diagnosed with heart failure before admission to hospital were low, and few patients with ejection fraction ≤ 40 % were discharged with recommended medication. Patients reported a need for more follow-up and primarily wanted follow-up at home via telephone or digital remote monitoring. To the best of our knowledge, this is the first Norwegian study of a patient cohort from daily clinical practice admitted to hospital with acute heart failure on a rolling basis. The study inclusion criteria were broad and only required that patients could attend a 15-minute interview with a cardiac nurse near the end of their hospital stay. It is therefore thought-provoking that almost 40 % were considered too ill/frail or cognitively impaired to participate. Acute and potentially reversible cardiological conditions such as myocardial infarction, tachyarrhythmia, aortic stenosis and myocarditis were the reason for admission in one-third. The findings in the study, especially the significant proportion of frail older patients, highlight the need for close cooperation between cardiologists and geriatricians in the treatment of patients admitted to hospital with heart failure (14) .
The need for prioritisation and the lowest effective level of care principle as the basis for the division of labour in the healthcare service has recently been highlighted (15) . In light of the study's findings, it is worth considering whether palliative care at home or in a nursing home might be a better alternative for many of these patients.
The patient's own wishes in terms of care and treatment, such as hospitalisation, life-sustaining interventions and symptom relief in the end-of-life phase, can be identified through advance care planning (ACP) (16, 17) . The effect of implementing ACP in clinical practice will now be tested in a Norwegian multicentre study (ClinicalTrials.gov: NCT05681585).
Demographic and clinical characteristics (including age, sex, comorbidity and left ventricle ejection fraction) of the patients in our study are well-aligned with Swedish data from clinical practice (5) and data from a recently published intervention study in the United States (13) . In line with data from these studies and from the Norwegian Prescription Database (7) , we find suboptimal prescription of the four drug classes that are strongly recommended for patients with heart failure with ejection fraction ≤ 40 % (1) . There was suboptimal prescription of SGLT2 inhibitors and mineral receptor antagonists in almost 60 % of patients and ACE/angiotensin II inhibitors or combination drugs with neprilysin inhibitor in 24 %. Severe renal failure is the main contraindication for these medications, but more than eight out of ten patients had an estimated glomerular filtration rate above 30 mL/min/1.73 m2 . Nevertheless, many of the participants are multimorbid. Hypotension with a risk of falls, and polypharmacy with an increased risk of adverse effects and interactions may partly explain the low prescription rate of highly recommended heart failure medications.
Self-reported adherence to heart failure medication in the week prior to admission to hospital was high (> 90 %) in our study, while 12-month persistent adherence in a Norwegian registry study was 60–80 % (7) . This difference may be the result of variations in when and how adherence was measured. The patients in our study were interviewed about adherence by a nurse. It has been shown that a high level of adherence is often over-reported by patients (18) . Furthermore, it is not inconceivable that the patients have taken their medications more regularly in the period prior to admission to hospital when they experienced exacerbated symptoms. On the other hand, the majority of patients in our study used a pill box or multidose dispenser, which improves drug adherence (1, 8) . Six out of 31 patients with heart failure with an ejection fraction above 40 % were prescribed an SGLT2 inhibitor, which is now strongly advised (1) . It is likely that the prescription rate will increase as soon as an independent reimbursement system is established.
Outpatient heart failure clinics in Norway are mainly staffed by nurses with specialist expertise in working closely with a cardiologist (4) . They provide patient education, self-care support, clinical examinations, functional testing and medication adjustments (1, 5) . An older Norwegian study (19) and international literature reviews (20) have documented that an outpatient follow-up programme led by a specialist nurse improves medication adherence, enhances self-care, increases physical capacity and improves quality of life. Despite strong recommendations (class 1A) and robust scientific evidence of the benefits of outpatient heart failure clinics in the specialist health service (1) , only a few patients in Norway receive these services due to limited capacity (4) . Accordingly, more than 70 % of the patients in our study were discharged without planned outpatient follow-up. It is also worth noting that about 1 in 3 patients wanted such follow-up. Lack of follow-up can be one of several reasons for the low level of self-care.
The low scores in terms of knowledge about the condition and heart medications in patients who had previously been hospitalised for heart failure is concerning, and almost none of the patients had a self-care plan, including adjustments of diuretics after weight changes, lifestyle advice and temporary discontinuation of certain medications (particularly ACE/A2 inhibitors and SGLT2 inhibitors) in cases of intercurrent illness. Since gradually increasing overhydration and congestion were the predominant reasons for admission, education on regular weighing and adjustment of diuretics and fluid intake is essential.
Overall, there appears to be a marked potential to strengthen both self-care and health literacy in patients readmitted with heart failure. International consensus documents highlight low health literacy and self-care skills as key challenges among heart failure patients, and they call for measures to strengthen this (8) . More than half of the patients reported a need for further follow-up, and it is interesting that significantly more patients preferred digital or telephone follow-up at home rather than physical attendance at the outpatient clinic.
The main strengths of the study are the prospective and continuous inclusion of patients at two large hospitals. The 30-day mortality rate of all patients with heart failure in Drammen and Vestfold is lower than the national average, while the proportion attending outpatient heart failure clinics, as well as other quality indicators at these hospitals, is higher than the national average (4) . It is therefore reasonable to assume that the heart failure population at these hospitals is not more frail or multimorbid than at other Norwegian hospitals, but given the high proportion of patients who were excluded, we cannot rule this out. We consider the quality of the data to be high since interviews were conducted by cardiology nurses who work with heart failure patients on a regular basis. Cardiologists with research expertise have quality assured all heart failure diagnoses and clinical data.
Based on the median frailty score of 4, it was somewhat surprising that self-care was not better, but the high median age may be a possible explanation. The interview guide used has not been validated, and reporting bias cannot be ruled out. The clinical frailty scale has also not been validated in patients admitted to hospital with heart failure. Although most patients (85 %) had an echocardiogram performed during their hospital stay or within the last three months, we cannot rule out the reported ejection fraction having changed in some patients. Patients were screened two days per week throughout the inclusion period. There may therefore be patients who meet the inclusion criteria but who were not included due to a lack of screening. Based on length of stay, this will only apply to a small number of patients, and we have no reason to believe that this has led to systematic biases in the dataset.
We have initiated a randomised controlled trial (ClinicalTrials.gov: NCT05447598) in which we will investigate whether individually tailored digital remote monitoring by hospitals is feasible after admission for heart failure. We will also examine whether it enhances self-care and reduces the risk of readmission.
Summary
Summary
The study participants who were included during hospital stays for acute heart failure had a median age of 79 years, significant comorbidity, one-third were frail and many had previously been admitted to hospital for heart failure. Self-care and health literacy levels were low in the patients who had already been diagnosed with heart failure, and there was a marked potential to optimise well-documented pharmacotherapy for heart failure.