, Check-list de sortie élaborée par le Groupe Insuffisant Cardiaque et cardiomyopathie, Annexe, vol.3

O. Oms-|-maladies-cardiovasculaires,

. Disponible,

, Taux de patients hospitalisés pour insuffisance cardiaque en 2008 et évolutions en, p.11, 2017.

K. M. , Insuffisance cardiaque. Les progrès médicamenteux devancent ceux de l'organisation des soins, 17 juin, vol.135, issue.6, p.442, 2013.

C. Pérel and F. Chin1, Philippe Tuppin2, Nicolas Danchin3, François Alla2, Yves Juillière4, Christine de Peretti1. Taux de patients hospitalisés pour insuffisance cardiaque en, 2002.

F. Dievart, Etude SHIFT: l'ivabradine devient un traitement de l'insuffisance cardiaque, pp.25-30, 2010.

S. Laribi, A. Aouba, M. Nikolaou, J. Lassus, A. Cohen-solal et al., Trends in death attributed to heart failure over the past two decades in Europe, Eur J Heart Fail. mars, vol.14, issue.3, pp.234-243, 2012.

P. Tuppin, A. Cuerq, C. De-peretti, A. Fagot-campagna, N. Danchin et al., Twoyear outcome of patients after a first hospitalization for heart failure: A national observational study, Arch Cardiovasc Dis. mars, vol.107, issue.3, pp.158-68, 2014.

C. Solal, A. Leurs, I. Assyag, P. Beauvais, F. Clerson et al., Optimization of heart FailUre medical Treatment after hospital discharge according to left ventricUlaR Ejection fraction: the FUTURE survey, Arch Cardiovasc Dis. juill, vol.105, issue.6-7, pp.355-65, 2012.

S. Setoguchi, L. W. Stevenson, and S. Schneeweiss, Repeated hospitalizations predict mortality in the community population with heart failure, Am Heart J. août, vol.154, issue.2, pp.260-266, 2007.

A. P. Maggioni, S. D. Anker, U. Dahlström, G. Filippatos, P. Ponikowski et al., Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry, Eur J Heart Fail, vol.15, issue.10, pp.1173-84, 2013.

, Guide du parcours de soins: Insuffisance cardiaque. HAS, 2014.

M. Komajda, P. Lapuerta, N. Hermans, J. R. Gonzalez-juanatey, D. J. Van-veldhuisen et al., Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey, Eur Heart J. août, vol.26, issue.16, pp.1653-1662, 2005.

P. Ponikowski, A. A. Voors, S. D. Anker, H. Bueno, J. Cleland et al., , 2016.

, ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure, Rev Espanola Cardiol Engl Ed. déc, vol.69, issue.12, p.1167, 2016.

J. Merlière, C. Couvreux, L. Smadja, and A. Jolivet, Caractéristiques et trajet de soins des insuffisants cardiaques du Régime général, août, issue.38, 2012.

O. Connor, C. M. Abraham, W. T. Albert, N. M. , C. R. et al., Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), Am Heart J. oct, vol.156, issue.4, pp.662-73, 2008.

P. Tuppin, A. Cuerq, C. De-peretti, A. Fagot-campagna, N. Danchin et al., First hospitalization for heart failure in France in 2009: patient characteristics and 30-day follow-up, Arch Cardiovasc Dis, vol.106, issue.11, pp.570-85, 2013.

M. S. Al-omary, A. A. Khan, A. J. Davies, P. J. Fletcher, D. Mcivor et al., Outcomes following heart failure hospitalization in a regional Australian setting between, ESC Heart Fail, 2005.

L. Prado and . Service-de-retour-À, , p.11, 2017.

. Disponible, , 2018.

, Chiffres clés : Cardiologue

P. Médecin, , 2014.

. Disponible,

, Infirmiers libéraux: démographie et activités. Comission des comptes de la sécurité sociale, pp.10-11, 2009.

G. Marc-andré, A. P. Jean-claude, R. Laure, V. , and B. Ventelou, Pierre VERGER-Remerciements à Isabelle CLERCet Sophie ROLLAND. Les pratiques en médecine générale dans cinq régions, vol.8, 2009.

M. Florian, Opinion des médecins généralistes sur les programmes d'éducation thérapeutique hospitaliers. L'exemple du programme I-CARE du CHU de Bordeaux, 2004.

L. Prado and . Service-de-retour-À, , p.11, 2017.

P. Alain, G. Marc-andré, C. Sandrine, Y. Obadia, ,. et al., Éducation thérapeutique des patients et hospitalisation à domicile. DRESS, 2011.

P. Protocoles, les infirmières libérales dubitatives-Actusoins

, Toute l'actualité infirmière avec Actusoins, 2017.

C. Tribouilloy, D. Rusinaru, H. Mahjoub, V. Soulière, F. Lévy et al., Prognosis of heart failure with preserved ejection fraction: a 5 year prospective population-based study, Eur Heart J. févr, vol.29, issue.3, pp.339-386, 2008.

, Comment améliorer la qualité et la sécurité des prescriptions de médicaments chez la personne âgée? HAS, 2014.

A. Maisel, D. Barnard, B. Jaski, G. Frivold, J. Marais et al., Primary results of the HABIT Trial (heart failure assessment with BNP in the home), J Am Coll Cardiol. 23 avr, vol.61, issue.16, pp.1726-1761, 2013.

A. S. Maisel, K. S. Shah, D. Barnard, B. Jaski, G. Frivold et al., How B-Type Natriuretic Peptide (BNP) and Body Weight Changes Vary in Heart Failure With Preserved Ejection Fraction Compared With Reduced Ejection Fraction: Secondary Results of the HABIT (HF Assessment With BNP in the Home) Trial, J Card Fail. avr, vol.22, issue.4, pp.283-93, 2016.

O. Connor, C. M. Miller, A. B. Blair, J. Konstam, M. A. Wedge et al., Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction: results from Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) program, Am Heart J. mai, vol.159, issue.5, pp.841-849, 2010.

S. D. Solomon, J. Dobson, S. Pocock, H. Skali, J. Mcmurray et al., Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation. 25 sept, vol.116, pp.1482-1489, 2007.

J. Mant, J. Doust, A. Roalfe, P. Barton, M. R. Cowie et al., Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care, Health Technol Assess Winch Engl. juill, vol.13, issue.32, pp.1-207, 2009.

F. A. Mcalister, E. Youngson, J. A. Bakal, P. Kaul, J. Ezekowitz et al., Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure, CMAJ Can Med Assoc J J Assoc Medicale Can, vol.185, issue.14, pp.681-689, 2013.

J. G. Baggs, M. H. Schmitt, A. I. Mushlin, P. H. Mitchell, D. H. Eldredge et al., Association between nurse-physician collaboration and patient outcomes in three intensive care units, Crit Care Med. sept, vol.27, issue.9, pp.1991-1999, 1999.

M. Manojlovich, Power and empowerment in nursing: looking backward to inform the future, Online J Issues Nurs. 31 janv, vol.12, issue.1, p.2, 2007.

M. John, Eisenberg Center for Clinical Decisions and Communications Science. Transitional Care Interventions To Prevent Readmissions for People With Heart Failure, Comparative Effectiveness Review Summary Guides for Policymakers

, Agency for Healthcare Research and Quality (US), AHRQ Comparative Effectiveness Reviews). Disponible sur, p.14, 2011.

A. P. Ambrosy, G. C. Fonarow, J. Butler, O. Chioncel, S. J. Greene et al., The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries, J Am Coll Cardiol. 1 avr, vol.63, issue.12, pp.1123-1156, 2014.

S. D. Solomon, B. Claggett, A. S. Desai, M. Packer, M. Zile et al., Influence of Ejection Fraction on Outcomes and Efficacy of Sacubitril/Valsartan (LCZ696) in Heart Failure with Reduced Ejection Fraction: The Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF), Trial. Circ Heart Fail. mars, vol.9, issue.3, p.2744, 2016.

D. Logeart, R. Isnard, M. Resche-rigon, M. Seronde, P. De-groote et al., Current aspects of the spectrum of acute heart failure syndromes in a real-life setting: the OFICA study, Eur J Heart Fail. avr, vol.15, issue.4, pp.465-76, 2013.
URL : https://hal.archives-ouvertes.fr/hal-00880093

C. Bonnet, I. Millot, A. Achouba, M. Czekala, C. Thonnelier et al., Survie et réhospitalisation après une première hospitalisation pour insuffisance cardiaque en France : étude de cohorte nationale à partir de la base de données « échantillon généraliste des bénéficiaires » (EGB), Rev DÉpidémiologie Santé Publique. 1 déc, vol.64, p.298, 2016.

. Soto-a, Gestion en médecine ambulatoire des patients insuffisant cardiaque à leur sortie d'hôpital, 2017.

M. G. Crespo-leiro, S. D. Anker, A. P. Maggioni, A. J. Coats, G. Filippatos et al., European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1year follow-up outcomes and differences across regions, Eur J Heart Fail, vol.18, issue.6, pp.613-638, 2016.

G. D. Schiff, S. Fung, T. Speroff, and R. A. Mcnutt, Decompensated heart failure: symptoms, patterns of onset, and contributing factors, Am J Med. 1 juin, vol.114, issue.8, pp.625-655, 2003.

J. R. Kapoor, R. Kapoor, C. Ju, P. A. Heidenreich, Z. J. Eapen et al.,

, Precipitating Clinical Factors, Heart Failure Characterization, and Outcomes in Patients Hospitalized With Heart Failure With Reduced, Borderline, and Preserved Ejection Fraction, JACC Heart Fail. 1 juin, vol.4, issue.6, pp.464-72, 2016.

J. Krupicka, T. Janota, and J. Hradec, Natriuretic peptides in heart failure, Cor Vasa. 1 août, vol.55, issue.4, pp.370-376, 2013.

, Optimiser la prise en charge à la sortie d'hospitalisation | Cardiologie Pratique

M. R. Cowie, Y. M. Lopatin, C. Saldarriaga, C. Fonseca, D. Sim et al., The Optimize Heart Failure Care Program: Initial lessons from global implementation, Int J Cardiol. 1 juin, vol.236, pp.340-344, 2017.

H. R. Omar and M. Guglin, Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE Trial, BioMed Res Int, p.5734749, 2017.

W. T. Abraham, G. C. Fonarow, N. M. Albert, W. G. Stough, M. Gheorghiade et al., Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), J Am Coll Cardiol. 29 juill, vol.52, issue.5, pp.347-56, 2008.

M. T. Vidán, V. Blaya-novakova, E. Sánchez, J. Ortiz, J. A. Serra-rexach et al., Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure, Eur J Heart Fail. 1 juill, vol.18, issue.7, pp.869-75, 2016.

M. Toma, J. A. Ezekowitz, J. A. Bakal, O. Connor, C. M. Hernandez et al., The relationship between left ventricular ejection fraction and mortality in patients with acute heart failure: insights from the ASCEND-HF Trial, Eur J Heart Fail. 1 mars, vol.16, issue.3, pp.334-375, 2014.

P. Ponikowski, A. A. Voors, S. D. Anker, H. Bueno, J. Cleland et al., , 2016.

, ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC), Eur J Heart Fail. août, vol.18, issue.8, pp.891-975, 2016.

H. R. Omar and M. Guglin, Discharge BNP is a stronger predictor of 6-month mortality in acute heart failure compared with baseline BNP and admission-to-discharge percentage BNP reduction, Int J Cardiol, vol.221, pp.1116-1138, 2016.

P. Lourenço, A. Ribeiro, M. Pintalhão, S. Silva, and P. Bettencourt, Predictors of Six-Month Mortality in BNP-Matched Acute Heart Failure Patients, Am J Cardiol. 1 sept, vol.116, issue.5, pp.744-752, 2015.

L. Eurlings, P. Van-pol, W. E. Kok, S. Van-wijk, C. Lodewijks-van-der-bolt et al., Management of chronic heart failure guided by individual N-terminal proB-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study, J Am Coll Cardiol. 14 déc, vol.56, issue.25, pp.2090-100, 2010.

H. Persson, H. Erntell, B. Eriksson, G. Johansson, K. Swedberg et al., Improved pharmacological therapy of chronic heart failure in primary care: a randomized Study of NT-proBNP Guided Management of Heart Failure-SIGNAL-HF (Swedish Intervention study-Guidelines and NT-proBNP AnaLysis in Heart Failure), Eur J Heart Fail. déc, vol.12, issue.12, pp.1300-1308, 2010.

M. R. Shah, R. M. Califf, A. Nohria, M. Bhapkar, M. Bowers et al., The STARBRITE trial: a randomized, pilot study of B-type natriuretic peptide-guided therapy in patients with advanced heart failure, J Card Fail. août, vol.17, issue.8, pp.613-634, 2011.

M. Pufulete, R. Maishman, L. Dabner, S. Mohiuddin, W. Hollingworth et al., Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model, Health Technol Assess Winch Engl. août, vol.21, issue.40, pp.1-150, 2017.

A. Basoor, N. C. Doshi, J. F. Cotant, T. Saleh, M. Todorov et al., Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure, Congest Heart Fail Greenwich Conn. août, vol.19, issue.4, pp.200-206, 2013.

C. J. Patterson and G. P. Mulley, The effectiveness of predischarge home assessment visits: a systematic review, Clin Rehabil. avr, vol.13, issue.2, pp.101-105, 1999.

, Haute Autorité de Santé-Plan personnalisé de santé (PPS) PAERPA

. Disponible,

G. Audi, A. Korologou, I. Koutelekos, G. Vasilopoulos, K. Karakostas et al., Factors Affecting Health Related Quality of Life in Hospitalized Patients with Heart Failure, Cardiol Res Pract, p.4690458, 2017.

S. I. Chaudhry, J. A. Mattera, J. P. Curtis, J. A. Spertus, J. Herrin et al., Telemonitoring in patients with heart failure, N Engl J Med. 9 déc, vol.363, issue.24, pp.2301-2310, 2010.

, Télésuivi de l'insuffisance cardiaque: premier déploiement de Chronic Care Connect*, à Marie-Lannelongue (Hautes-de-Seine), 2017.