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Primary care plays crucial role in heart failure management.

Heart failure management has become increasingly complex, with new drugs and drug combinations, new uses for potentially life-saving implanted devices, and a more sophisticated appreciation of how comorbidities complicate a heart failure patient's clinical status.

Despite those changes, care for the vast majority of U.S. patients with heart failure remains in the hands of internal medicine physicians and general cardiologists.

To some extent, this is a manpower issue. The estimated number of Americans living with heart failure exceeds 5 million, a figure that dwarfs the very modest number of U.S. physicians and clinicians who are certified or self-identified heart failure specialists.

The expanded dimensions of heart failure care resulted in the establishment in 2008 of a new secondary subspecialty, Advanced Heart Failure and Transplant Cardiology, aimed at training and certifying physicians in all the nuances of complex heart failure diagnostics and care.

Yet, as of today, fewer than 1,000 U.S. physicians have received formal certification as heart failure sub-specialists through the examination administered in 2010, 2012, and 2014, said Michele Blair, chief executive officer of the Heart Failure Society of America.

A more liberal definition of a heart failure specialist might include the roughly 3,000 unique physicians (mostly cardiologists, but also some hospitalists and emergency physicians) who have recently attended an annual meeting of the HFSA, as well as the roughly 2,300 physician assistants and nurse practitioners who have shown a heart failure interest by coming to a recent HFSA meeting.

But even these expanded estimates calculate out to about 1 clinician with a special interest in heart failure for each 1,000 heart failure patients, not a very reassuring ratio.

The burgeoning numbers of heart failure patients, compared with the relative scarcity of both heart failure experts and general cardiologists, raises issues of how internists best share this management responsibility. Recent interviews with several heart failure subspecialists and internists provide some insight into how this division of labor is now playing out in routine U.S. practice.

What often occurs is that internists take exclusive responsibility for caring for heart failure patients until they feel they are getting in over their heads, at which time they'll consult with a cardiology colleague or refer the patient to a cardiologist.

That moment of recognition by the generalist--that the demands and complexity of the case exceed their comfort level--varies widely. Some primary care physicians referring patients as soon as heart failure symptoms appear, while others stay comfortable as the primary care giver even as a patient's disease deteriorates to a more advanced stage.

Heart failure specialists highlighted their reliance on PCPs to take an ongoing, active role even for patients with significantly advanced heart failure. Generalists are well suited to coordinating the multispecialty care that such patients usually require, with attention to their need for lifestyle modifications as well as management of their diabetes, sleep apnea, chronic obstructive pulmonary disease, renal failure, and other comorbidities.

As Dr. Michael K. Ong, an internist at the University of California, Los Angeles, said in an interview, his heart failure specialist colleague manages patients' heart failure; "I manage [or refer] everything else not directly related to the heart failure."

The most successful U.S. care models seem to be some variation on a team-care approach, in which physicians collaborate with pharmacists, nurses, rehabilitation specialists, and social workers, as well as specialists. That team would include and perhaps be led by either an internist, a cardiologist, or a heart failure specialist, but would also broadly include physicians able to deal with all the morbidity facets of heart failure.

It's a model that remains unavailable in many U.S. settings or is just starting to emerge, as fee-for-service coverage of patients gets replaced by population-management models that better accommodate the upfront financial demands of coordinated team care. It makes financial sense a few years down the road, when improved patient outcomes result in cost savings.

The heart failure definitions and staging system established in 2001 by a guidelines panel of the American College of Cardiology and American Heart Association defined stage A heart failure as starting before a patient exhibits any heart failure symptoms (the classic ones include dyspnea, rales, and peripheral edema). The panel designated symptomatic heart failure patients as stage C. Patients without heart failure symptoms but with one or more risk factors (such as hypertension, diabetes, obesity, and cardiovascular disease) plus structural heart disease (such as cardiomyopathy or other forms of heart remodeling) were designated stage B. The panel said that people at stage A had one or more risk factors but no structural heart changes and no heart failure symptoms.

Although stage A heart failure patients are clearly the types of people most often seen and cared for by PCPs, many of these physicians, as well as many heart failure specialists, don't consider patients who have only hypertension or only diabetes or only obesity as yet having heart failure.

That paradox deserves more discussion, but the best way to begin talking about PCPs and heart failure patients is when patients are symptomatic and have what everyone would agree is heart failure.

Even though the ACC/AHA staging system places stage C patients well down the heart failure road, stage C is usually when patients are first diagnosed with heart failure. The diagnosis often is made first by a hospitalist or emergency physician when severe and sudden-onset heart failure symptoms drive the patient to a hospital, or by a cardiologist or heart failure specialist when the patient's presentation and differential diagnosis isn't straightforward.

Most commonly, however, the diagnosis starts with a PCP in an office encounter with a patient who is symptomatic but not acutely ill.

"Patients with shortness of breath or other forms of effort intolerance most often seek care from PCPs. The differential diagnosis of dyspnea is long and complex. Recognition that a patient with dyspnea may have HF is crucial" for timely management and treatment, said Dr. Mary Norine Walsh, medical director of Heart Failure and Cardiac Transplantation at St. Vincent Heart Center in Indianapolis.

At the Mayo Clinic in Rochester, Minn., "most of the heart failure diagnoses are done by PCPs, usually first identified at stage C when a patient comes in with symptoms. Stage B heart failure is usually only identified as an incidental finding when echocardiography is done for some other reason," said Dr. Paul M. McKie, a heart failure cardiologist who works closely with the primary care staff at Mayo as an embedded consultant cardiologist.

According to Dr. Mariell L. Jessup, a heart failure physician and professor at the University of Pennsylvania in Philadelphia, a key to PCPs promptly identifying patients with recent-onset, stage C heart failure is to keep the disease as well as its prominent risk factors at the top of their differential-diagnosis list for at-risk patients.

"Heart failure is a common disorder," Dr. Jessup said, and must be considered for patients with shortness of breath. "The leading causes of heart failure are hypertension, obesity, and diabetes. So keep heart failure in mind, especially for patients with one or more of these risk factors."

Although PCPs might order an echocardiography examination or a lab test such as measurement of brain natriuretic protein (BNP) to help nail down the diagnosis, they often leave reading the echocardiography results to a cardiologist colleague.

"When a PCP orders an echo, it's automatically read by a cardiologist, and then we get the cardiologist's report. I don't read echos myself," said Dr. Rebecca J. Cunningham, an internist at Brigham and Women's Hospital in Boston who frequently sees patients with heart failure as medical director of the hospital's Integrated Care Management Program. "I had one PCP colleague who undertook additional training to learn to read echos himself, but that's unusual."

Dr. Mary Ann Bauman, an internist and medical director for Women's Health and Community Relations at INTEGRIS Health in Oklahoma City, noted a similar division of labor.

"If a patient has shortness of breath, maybe some edema, and I hear a few rales, but is totally functional, I always order an echo, but I don't read it. I refer the echo to a cardiologist who then sends me a report," Dr. Bauman said in an interview. "If I think the patient may have heart failure, I'll also order a BNP or NT-proBNP test. If I suspect heart failure and the BNP is high, it's a red flag. BNP is another tool for getting the diagnosis right."

The next step seems much more variable. Some PCPs retain primary control of heart failure management for many of their patients, especially when stage C patients remain stable and functional on simple, straightforward treatment - and particularly when they have heart failure with preserved ejection fraction (HFpEF), usually defined as a left ventricular ejection fraction that is at least 40%-45%.

Consultation or referral to a cardiologist or heart-failure physician seems much more common for patients with frequent decompensations and hospitalizations or patients with heart failure with reduced ejection fraction (HFrEF). But the main thread reported by both PCPs and cardiologists is that it all depends and varies for each patient - and for each PCP - depending on what patient responsibilities a PCP feels comfortable taking on.

Dr. Bauman sits at one end of the spectrum.

"If it looks like a patient has heart failure, I refer them right away; I don't wait for decompensation to occur," she explained. "I want to be sure that there are no nuances in the patient that need something before I recognize it. Most of my PCP partners do the same. You don't know what it is you don't know.

"For me, it's better to refer the patient right away so the patient has a cardiologist who already knows them who can be called if they start to decompensate," she noted.

Dr. Bauman cited the increasing complexity of heart failure management as the main driver of her cur rent approach, which she contrasted to how she dealt with heart failure patients 20 years ago.

"It's become so complicated that, as a PCP, I don't feel that I can keep up" with the optimal ways to manage every heart failure patient. "I might not give my heart failure patients the best care they could receive."

The aspects of care that Dr. Bauman said she can provide to heart failure patients she has referred include "dealing with lifestyle changes, making sure patients are taking their medications and getting to their appointments, adjusting their heart failure medication dosages as needed once they start on the drugs, and seeing that their diabetes and hypertension are well controlled. That is the role of the PCP. But when it comes to deciding which HF medications to use, that's when I like to have a cardiologist involved."

But the PCPs at Mayo Clinic often take a different tack, said Dr. McKie.

"If the patient is a simple case of heart failure with no red flags, and the patient is doing relatively well on treatment with simple diuretic treatment, then initiation of heart failure medications and ongoing management is often directed by the PCP with some cardiology backup as needed," he said.

But Dr. McKie conceded that a spectrum of PCP approaches exists at Mayo as well. "A lot depends on the patient and on the specific provider. Some patients we never get calls about; their PCPs are excellent at managing diuretics and uptitrating beta-blockers and ACE inhibitors. We may only get called if the patient decompensates.

"But other PCPs are very uncomfortable, and they request that we get involved as soon as the diagnosis of stage C heart failure is made," he added. "So, there is a wide range."

Dr. McKie noted that he thinks it is appropriate for himself or one of his cardiology colleagues to get more active when the HFrEF patient's ejection fraction drops below 40%, and certainly below 35%. That's because at this stage, patients also need treatment with an aldosterone receptor antagonist such as spironolactone, and they undergo consideration for receiving an implantable cardioverter defibrillator or a cardiac resynchronization therapy device.

"There is nothing magic about heart failure management; it is very well prescribed by guidelines. Nothing precludes a primary care physician from taking ownership" of heart failure patients, said Dr. Akshay S. Desai, a heart failure cardiologist at Brigham and Women's Hospital. "I think there is some fear among PCPs that they intrude" by managing heart failure patients.

But for patients with structural heart disease or even left ventricular dysfunction, "PCPs should feel empowered to start standard heart failure treatments, including ACE inhibitors and beta-blockers, especially because half of heart failure patients have HFpEF, and PCPs often don't refer HFpEF patients to cardiologists," Dr. Desai said. "It's the patients with left ventricular dysfunction who end up in heart failure clinics."

On the other hand, Dr. Desai cautioned PCPs against waiting too long to bring more complex, sicker, and harder-to-manage patients to the attention of a heart failure specialist.

"What we worry about are late referrals, when patients are profoundly decompensated," he said. "By the time they show up [at a heart failure clinic or emergency department] they have end-organ dysfunction," which makes them much harder to treat and maybe irreversible.

"Recognizing heart failure early is the key, and early referral is an obligation" when a heart failure patient is deteriorating or becomes too complex for a PCP to properly manage, Dr. Desai advised.

But even when heart failure patients develop more severe disease, with significantly depressed left ventricular function or frequent decompensations, PCPs continue to play a valuable role in coordinating the wide range of treatments patients need for their various comorbidities.

"Once a cardiologist or heart failure physician is involved, there is still a role for PCPs" said Dr. Monica R. Shah, deputy chief of the Heart Failure and Arrhythmia Branch of the National Heart, Lung, and Blood Institute in Bethesda, Md.

"Heart failure patients are complex; it's not just one organ system that's affected, and you need a partnership between cardiologists and PCPs to coordinate all of a patient's care," Dr. Shah noted. 'A heart failure physician needs to work with a PCP to be sure that the patient's health is optimal. Collaboration between cardiologists and PCPs is key to ensure that optimal care is effectively delivered to patients."

"Keeping the PCP at the center of the care team is critical, especially with the multiple comorbidities that HF patients can have, including chronic obstructive pulmonary disease, diabetes, renal failure, sleep apnea, atrial fibrillation, and degenerative joint disease," explained Dr. McKie.

"Before you know it, you have a half-dozen subspecialists involved in care, and it can become uncoordinated," he added. "Keeping the PCP at the center of the team and providing the PCP with support from specialists as needed is critical."

Even for the most severe heart failure patients, PCPs can still play an important role by providing palliative care and dealing with end-of-life issues, specialists said.

Dr. Desai has been a consultant to Novartis, Merck, St. Jude, and Relypsa, and has received research funding from Novartis and AtCor Medical. Dr. Ong, Dr. Walsh, Dr. Jessup, Dr. McKie, Dr. Bauman, Dr. Shah, and Dr. Cunningham had no disclosures.

In our next issue: What role should primary care physicians play in presymptomatic, stage A heart failure?

On Twitter @mitchelzoler

Caption: Keep the disease and its prominent risk factors at the top of the differential-diagnosis list for at-risk patients, said Dr. Mariell L. Jessup.

Caption: Dr. Mary Norine Walsh

Caption: Dr. Michael K. Ong

Caption: Dr. Akshay S. Desai

Caption: Dr. Mary Ann Bauman

Caption: Dr. Paul M. McKie


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Title Annotation:CARDIOLOGY
Author:Zoler, Mitchel L.
Publication:Internal Medicine News
Date:Mar 1, 2016
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