Heart Failure Management Hinges on Care Collaboration

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With increasing numbers of Americans affected by heart failure, the healthcare system’s mantra for care is “teamwork.”

CVB_0306_04Acute heart failure accounts for more than one million primary hospitalizations annually, and more than three million contributing hospitalizations. It is the leading cause of hospitalization in patients over the age of 65—which will grow as the population ages. 

In September, the Agency for Healthcare Research and Quality (AHRQ) reported that hospitalizations for congestive heart failure increased by 3 percent during the last decade, rising to the second most common disease treated in hospitals in 2007.

Another AHRQ report released in May found that the “potentially preventable hospitalizations” associated with heart failure total $7.2 billion annually. The average hospital stay for a heart failure patient costs $6,000 to $12,000, according to the New England Healthcare Institute. As a result, the high rate of hospitalization has led to cost estimates for 2009 of more than $37 billion for heart failure care in the U.S. (Circulation 2009;119(3):480-6).

The leading causes of hospitalization include a failure to recognize worsening symptoms, patient noncompliance with medications and weight management, and a lack of cohesion between caregivers. “Even as we increase our compliance with beta blocker and ACE [angiotensin-converting enzyme] inhibitor recommendations, we are still seeing the readmission rates increase,” says William E. Chavey, MD, a practicing primary care physician and family medicine faculty member at the University of Michigan in Ann Arbor. “We also know that the single, biggest factor predicting admission for heart failure is prior admission. We’re attempting to manage a progressive condition that we cannot cure.” 

Statistics from the Veterans Administration suggest that readmission for heart failure occurs within 30 days following 20 percent of discharges, with similar rates in the Medicare system. This issue will continue to garner attention as third-party payors, including the Centers for Medicare & Medicaid Services (CMS), are becoming unwilling to reimburse for readmissions that occur within 30 days of discharge.

Initial Rx management

The care for early stage heart failure/pre-heart failure is well orchestrated by the guidelines, according to Clyde W. Yancy, MD, president of the American Heart Association (AHA). Asymptomatic patients with a reduced ejection fraction (EF) should adhere to ACE inhibitors or angiotensin receptor blockers (ARBs) and a beta blocker. “The earlier the intervention occurs with evidence-based therapy, the better,” says Yancy, medical director and chief of cardiothoracic transplantation at the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas. If a low EF (less than 30 percent) is due to ischemic heart disease, an implantable defibrillator might be warranted, along with standard drug therapy (ACE inhibitors/ARBs and beta blockers). “The benefit [of ICDs] appears to be strongest in those with mild or moderate disease, as opposed to advanced disease,” he says.

If the disease progresses to the development of symptoms, diuretics begin to play an important role in controlling a patient’s volume, especially in early-stage depressed left ventricular EF, says Marc Jay Semigran, MD, director of the heart failure program at Massachusetts General Hospital in Boston. Aldosetrone antagonists should be added if symptoms progress, and multiple diuretics may eventually be needed to control volume overload.

But early-stage patients tend to be managed by primary care physicians and it’s not clearly defined when a heart failure specialist should intervene, Chavey says. He acknowledges that some confusion may exist among primary care physicians about the management of heart failure—with a reduced or preserved EF. The growing consensus, voiced by Yancy, is that the “best care for heart failure patients seems to emanate from a team approach, led by a physician leader. That physician needs to be supported by physician extenders, such as nurses or physician assistants. Most importantly, this team needs to engage in an interactive, longitudinal patient-centric experience.”

Disease progression

Practitioners have multiple clinical trial results to guide drug dosages for progressing heart failure. One caveat, however, is the sensitivity for ACE inhibitors versus beta blockers. “To the best of our knowledge, the response to beta blockers is dose