Efficacy of a Disease Management Program in Very Old Patients With Heart Failure

Inclusion Criteria: 1. Age:75 y or older 2. Co-morbidity or dependency. At least one of the following criteria: Charlson index \>3, dependency in 2 or more basic activities of daily living,treatment with 5 or more drugs, urgent hospitalization in the last 3 months, three or more diseases with active treatment, limitation in daily living because of vision or hearing impairment, cognition deficit, Parkinson disease, diabetes mellitus, chronic obstructive lung disease, severe anemia, constitutional syndrome 3. Hospital admission with a main diagnosis of heart failure (according to the criteria of the European Society of Cardiology or Framingham criteria) in NYHA functional class II-IV. Exclusion Criteria: 1. Participation refusal 2. Terminal illness 3. Cognitive decline or severe cognitive deficit, which does not permit a minimum knowledge of the disease, or lack of carers which give consent to study participation 4. Clinical instability as assessed with the Kosecof index 5. Being in waiting list for organ transplant or cardiac surgery 6. Inability to be followed-up because of other reasons (change of place of residence,..) 7. Institutionalization