Changes, challenges in treating heart failure

Three years ago, a man diagnosed with heart failure was put on a minimum dosage of drugs. The amounts were never increased, but the man still received a defibrillator and a pacemaker. Because he continued to feel unwell, he was recently referred to cardiologist Ileana L. Piña, MD, MPH, at the heart failure program at the Montefiore Medical Center in Bronx, N.Y.

“Now his heart is so large I'm not sure we can reverse it,” she said. “Three years ago he had a 30% chance of reversal if treated medically aggressively. He may have lost that opportunity.”

She now sees the patient weekly and follows up by phone. Although she's increased the amount of medications he's taking, she said the outlook is dicey. “There's a chance he may need a new heart,” she said.

Dr. Piña and other experts attributed challenges like this in treating heart failure to changing patient demographics, increasingly sick patients being seen in the outpatient setting, promising new yet complicated medication options, and already overwhelmed primary care physician offices that are nonetheless considered the crucial link in monitoring and triage.

In a 2009 study published in the New England Journal of Medicine, heart failure was the most common reason for rehospitalization within 30 days following an index hospitalization. Moreover, more than half of patients overall readmitted after 30 days hadn't seen a primary care physician between discharge and readmission. The conclusion was that readmissions can be prevented with diligent, evidence-based primary care.

But with their time at a premium, physicians can be increasingly anxious about meeting the needs of heart failure patients, many of whom are often too sick or isolated to adhere to a complicated postdischarge regimen that may include as many as 15 medications, Dr. Piña said.

And the pressure on physicians is only going to intensify as the number of heart failure patients grows. The American Heart Association (AHA) estimates that there are 5.7 million Americans with heart failure and that the number will increase by 870,000 new cases each year.

William T. Abraham, MD, FACP, attributed that trend not only to the impact of an aging population but also to patients surviving early illnesses thanks to improved care for conditions like coronary heart disease and myocardial infarction.

“These patients now survive to develop heart failure,” said Dr. Abraham, director of the division of cardiovascular medicine at The Ohio State University Wexner Medical Center in Columbus and professor of medicine, physiology, and cell biology. “It used to be few would live more than 5 years, but now they survive for 10, 20, or more years.”

“Heart failure [treatment] is changing,” said Howard J. Eisen, MD, FACP, chief of the division of cardiology at Drexel University College of Medicine in Philadelphia. “It's a new era.”

What internists need to know

The most recent and most frequently recommended guidelines for treating heart failure patients are those released by the AHA and the American College of Cardiology (ACC) Foundation in 2013.

When the guidelines are applied appropriately, said Gregg C. Fonarow, MD, they can extend patients' survival. “It can make a tremendous difference as to whether [the patient] has a good outcome, real improvement, or relentless progression of disease, hospitalization, or even death,” he said.

However, ideal heart failure care is complicated and time consuming. “Patients are on multiple medications, need close monitoring and counseling about adherence to medications, frequent adjustment to medications, lifestyle modification, education on self-management, and monitoring of electrolytes,” said Dr. Fonarow, co-chief of the division of cardiology and professor of cardiovascular medicine at the David Geffen School of Medicine at the University of California, Los Angeles.

Dr. Abraham also pointed out that there is currently little evidence-based therapy for those with diastolic heart failure and that care for those patients is focused on treating comorbidities and symptoms, such as hypertension and shortness of breath, respectively.

The challenge is making sure time- and resource-crunched internists really know the guidelines and then find ways to put the recommendations into practice, Dr. Piña said. She urged internists to become more confident in the drug guidelines and in identifying patients who might benefit from treatment or monitoring, such as known heart failure patients or those who are at risk, including patients who are hypertensive, diabetic, obese, or even just older, especially women.

The AHA/ACC Foundation guidelines are lengthy but include an executive summary and tables that can be good, quick references for busy physicians, noted Dr. Piña, professor of medicine, epidemiology, and public health and associate chief for academic affairs at Montefiore. “I'm a big believer that primary care providers can do a good job in their offices using guideline-directed medical therapy,” she said.

However, she stressed that it's also important to realize when it's time to refer to a cardiologist or to a heart failure clinic, especially in situations where the patient's case may be especially complicated. “If you feel you can't do it, refer and refer early before the patient gets sick,” she said.

Adding to the complexity, 2 new heart failure drugs have recently been approved, in what Mariell Jessup, MD, called “unequivocal and outstanding” studies that showed a significant decrease in total deaths.

The first drug, sacubitril/valsartan, is a substitute for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-receptor blocker. The second, ivabradine, slows the heart rate. It is targeted to patients who are on a maximum dose of a beta-blocker and still have a heart rate above 70 beats/min.

However, although the drugs show promise, it's unclear how they should be optimally applied in practice. Because determining whether they are appropriate is complicated, “I wouldn't put a new heart failure patient on [either of] them just yet” as first-choice therapy, Dr. Abraham said.

Dr. Jessup, professor of medicine at the University of Pennsylvania School of Medicine and a heart failure cardiologist at the Penn Heart and Vascular Center in Philadelphia, noted that cardiologists as well as internists are calling her for help in determining which patients are the best candidates for the new medication.

“Time will tell, just like it did with ACE inhibitors,” she said. She also pointed out that the drugs are expensive, with sacubitril/valsartan, for example, costing approximately $4,500 per year. Specific recommendations on the use of these drugs are being incorporated into the updated AHA/ACCF guidelines, expected to be released later this year, Dr. Jessup said.

Key clinical strategies

Given the various physicians who might be caring for heart failure patients, communication via electronic medical records, e-mail, and/or texts<@EN_dash> even picking up the phone—is critical to improving patient outcomes and quality of life, said Dr. Jessup.

Other strategies include the following:

• See patients frequently, especially after a hospitalization. Busy practices that see these patients every 3 months instead of 2 or 3 weeks will lose momentum, Dr. Abraham said.
• Recognize how sick the patient is by matching him or her with the New York Heart Association (NYHA) Functional Classifications, said Dr. Eisen. Is the patient short of breath with activities of daily living such as brushing teeth or taking a shower? That's a NYHA class III. Is the patient waking up in the middle of the night short of breath? That's class IV and the patient needs to be sent to a cardiologist immediately, he said.
• Titrate medications slowly. This can be frustrating, but heart failure patients need to “start low and go slow with multiple medications” to increase tolerance and minimize side effects like hypotension and worsening kidney function, Dr. Abraham said. See the patient every couple of weeks to titrate the medications. In general, it takes 3 to 6 months to optimize treatment for a systolic heart failure patient, he said.
• Assess patients thoroughly at every visit. In addition to reviewing and adjusting medications, also review lifestyle habits and nutrition.
• Teach patients to self-assess and to call if they need to modify their diet after, for example, a fast-food binge, said Paul J. Mather, MD, FACP, director of the Advanced Heart Failure and Cardiac Transplant Center at Jefferson Heart Institute in Philadelphia.
• Know the guidelines cold and keep up to date on new therapy and changes in care, Dr. Fonarow said. He recommended the AHA's Get with the Guidelines program, which includes clinical decision support tools, patient education tools, and performance improvement registries.
• Discuss the prognosis with the patient and initiate advance care planning if appropriate, Dr. Fonarow said.

Overall, collaboration is key, according to Dr. Piña. “We can't do it alone anymore. That's not the way physicians generally think, but that ... must change,” she said. “We need to think in terms of teams.”

Dr. Abraham agreed. “If the primary care provider sees the heart failure patient every 2 to 3 months and the cardiologist once or twice in between ... it enhances overall patient care,” he said. “We create a win-win situation.”