Managing treatment for people with heart failure calls for continual monitoring and collaboration among physicians.
April 2024 – The Journal of Healthcare Contracting
More than 6 million adults in the United States have heart failure, and about 60% of people in the United States with heart failure are treated solely by primary care or internal medicine/family practice providers, says Nancy Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN, associate chief nursing officer, research and development, at Cleveland Clinic’s Stanley Shalom Zielony Institute for Nursing Excellence as well as past president of the Heart Failure Society of America. Even when hospitalized, some providers choose not to consult with a cardiology provider.
Cardiologists continue to play an important role, of course. Patients often seek a cardiologist’s care if they want a second opinion, or if they are hospitalized and a cardiologist is assigned to them. Nor are primary care physicians likely to lead the treatment of patients with heart failure that is due to genetic causes and high-risk, low-frequency causes.
“But there are not enough cardiologists to manage all heart failure patients in this country,” says Paul Heidenreich, M.D. professor and vice chair for quality, Department of Medicine, Stanford University School of Medicine. “Thus, many primary care physicians will help manage, or exclusively manage, those with mild heart failure.”
What is heart failure?
Heart failure often results from poor left ventricular function. It is the contraction of left ventricle of the heart that forces oxygenated blood through the aortic valve to be distributed to the entire body. With such an important role, decreased function can induce symptoms of the disease.
The “ejection fraction” is the amount of blood that the heart pumps each time it beats. It is measured as a percentage of the total amount of blood in the heart that is pumped out with each heartbeat. A normal ejection fraction is 50% or higher. An ejection fraction below 40% means the heart isn’t pumping enough blood and may be failing.
Adults may be at risk for heart failure when they have other forms of cardiovascular disease (e.g., high blood pressure, coronary heart disease, post myocardial infarction, valve disease, atrial fibrillation or other dysrhythmias), type 1 or 2 diabetes, obesity, chronic obstructive pulmonary disease or other conditions, says Nancy M. Albert PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN, associate chief nursing officer, research and innovation, at Cleveland Clinic’s Stanley Shalom Zielony Institute for Nursing Excellence.
Heart failure often displays itself with shortness of breath, fatigue, irregular heartbeat, abdominal discomfort and swelling in the legs and feet. Doctors are likely to order tests – most often, echocardiography – to determine ejection fraction, but they also rely on cardiac catheterization, magnetic resonance imaging, nuclear medicine scan or computerized tomography.
For their patients with shortness of breath and fatigue or leg weakness, primary care providers should obtain a NTproBNP lab test, which provides data on stress to the walls of the left ventricle, says Dr. Albert. If that test is elevated, they should order a 2-D echocardiogram and other lab (serum and urine) tests plus an electrocardiogram (12-led ECG) to rule heart failure in or out. The echocardiogram can also provide data on valve function and may help the provider understand the etiology of the heart failure.
There is evidence from a randomized trial that patients 40 and older with risk factors for heart failure (e.g., hypertension, diabetes, vascular disease including coronary artery disease) benefit from BNP screening to identify and treat unrecognized left ventricular dysfunction, adds Dr. Heidenreich.
Avoiding hospitalization
The primary care physician’s role in treating people with heart failure is like that of the cardiologist, if they are the sole provider of heart failure care, says Dr. Albert. That role includes determining the cause of heart failure (and then treating it, if modifiable), conducting regular assessments, testing for improvement or worsening of the condition, and initiating and optimizing heart failure medications.
Adds Dr. Heidenreich, if a specialist is managing the condition, the primary care physician should monitor for a decline in the patient’s health status and notify the specialist of any change. The specialist’s treatment plan should be made clear to the primary care physician, and if there is concern that this plan is not following recommended guidelines, the primary care provider should raise these concerns with the specialist.
An important goal for any doctor treating patients with heart failure is to help them avoid hospitalization.
Says Dr. Albert, in general, neurohormones are produced when the heart is under stress, during “decompensation.” The neurohormones that are released make the heart work harder and affect the kidney as well, leading to worsening heart and kidney function. They also cause symptoms (e.g., difficulty breathing) that bring the patient into the hospital. Even after reducing symptoms of an acute episode, the neurohormones in the body may still be activated and can lead to worsening outcomes.
Some patients are hospitalized for acute decompensated heart failure because they fail to follow lifestyle recommendations, such as eating a heart-healthy diet, stopping smoking, walking every day, decreasing sodium content in foods eaten, getting a flu shot, managing high blood pressure or high lipid levels, or taking their medications as prescribed. “In these cases, it is very important for providers to educate patients on lifestyle and medications so that patients understand instructions (what, how, why, when…) and can be adherent,” says Dr. Albert.
The other way providers can help patients avoid hospitalization is by prescribing evidence-based heart failure medications, she says. There are four classes of medications patients with heart failure and reduced ejection fraction should be on: renin-angiotensin system inhibitors (ACEi, ARB or ARNI), beta-blockers (evidence-based), mineralocorticoid receptor blockers, and sodium glucose co-transporter inhibitors.
Not for lone wolves
Managing treatment for people with heart failure calls for continual monitoring by the primary care team and ongoing collaboration with specialists and the patients (and/or their caregivers) themselves. The reason is, heart failure is complicated.
According to the American College of Cardiology, more than 50% of Medicare patients with heart failure have four or more non-cardiovascular comorbidities (e.g., obesity, chronic lung disease, diabetes, chronic renal disease, etc.). More than 25% have six or more, raising the risk of inefficiencies of care delivery, miscommunication, potential drug-drug interactions and drug-disease interactions, and missed opportunities to achieve optimal outcomes.
Says Dr. Albert, the primary care doctor should consult with an electrophysiologist cardiologist if a device is needed (pacemaker or implantable cardioverter-defibrillator); a structural heart disease cardiologist if valve repair is needed; an interventional cardiologist if a cardiac catheterization procedure is needed; or a cardiac surgeon if surgery is needed. If the patient’s condition matches criteria for advanced heart failure, the primary care provider should consult a heart failure specialty cardiologist or, at minimum, a general cardiologist.
“Providing guideline-recommended care, such as the 2022 ACC/AHA/HFSA Heart Failure Guideline, will help keep patients living healthier with fewer hospitalizations and greater survival,” adds Dr. Heidenreich. “Often the doctor needs help, and if they have team members able to prescribe and manage medications (nurse, pharmacist), they should optimize care.”
What’s coming up?
Drugs that lower blood pressure, improve the heart’s ability to pump blood, slow the heart rate and prevent scarring of the heart muscles play a big role in the treatment of heart failure. And there has been progress in recent years, including the introduction of drugs such as Verquvo, Entresto and Corlanor. A group of drugs called sodium-glucose cotransporter-2 (SGLT2) inhibitors is also showing promise for heart failure treatment.
Physicians have many non-medical options to ensure their patients adhere to an agreed-upon treatment regimen, according to the American College of Cardiology. They include:
- Understanding reasons for nonadherence, including patient factors (such as poor health literacy, perceived lack of effect, depression, social isolation, cognitive and physical impairment), medical condition (polypharmacy due to multiple comorbidities), therapy (frequency of dosing, side effects), socioeconomics (out-of-pocket cost, difficulty accessing a pharmacy), and shortcomings of the health system (poor communication, silos of care, lack of automatic refills).
- Shifting language away from patient “compliance” to “adherence,” “activation,” “engagement” or “empowerment,” emphasizing support, not blame.
- Starting guideline-directed medical therapy before the patient is discharged from the hospital, simplifying medication regimens, communicating with other clinicians involved in care, considering the impact of costs and access on their patients, recommending tools that support adherence in real-time (such as pillboxes filled by caregivers), anticipating problems (such as refills), and promoting motivational interviewing).
- Providing medication education, disease education, teaching of self-monitoring and self-management, and taking advantage of mobile health, such as reminders, warnings, and adherence tracking.
Editor’s note: The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, can be found at www.ahajournals.org/doi/full/10.1161/CIR.0000000000001063