Timing is crucial when it comes to referring heart failure patients for advanced therapy evaluation.
“Timely patient referral is critical to a good outcome and can enhance patient experiences and overall benefit of advanced therapies for heart failure,” says Michigan Medicine cardiac surgeon Francis Pagani, M.D.
This message is supported in a recent Journal of the American College of Cardiology report detailing guidelines for timely patient referral to a center specializing in transplantation and left ventricular assist devices to treat advanced heart failure.
Heart failure patients, particularly those in advanced stages, have better options and better outcomes when they’re seen in time, says Michigan Medicine cardiologist Abbas Bitar, M.D., who references the New York Heart Association Functional Classification when evaluating his patients, as follows:
Class I – No symptoms or limitation of physical activity.
Class II – Mild symptoms and slight limitation of physical activity.
Class III – Marked imitation of physical activity due to symptoms; comfortable mainly at rest.
Class IV – Unable to carry out any physical activity without discomfort; symptoms of cardiac insufficiency at rest.
“Over time these advanced stage patients (class III and IV) can improve, but chances of recovery are reduced if we are performing evaluations late, when advanced heart failure can damage other organs,” Bitar says. “If a patient doesn’t get referred to us in time, they might have liver damage, kidney damage or other organ dysfunction. When this happens, we often can’t help them.”
Left-sided heart failure that leads to right-sided heart failure can also prevent a patient from qualifying for an LVAD. However, Pagani says, “If we see a patient with significant right-sided heart failure early enough there’s a greater chance we can implant an LVAD successfully. Collaborating with referring physician colleagues allows us to work together to determine timing for referral to ensure the best outcome for each individual patient,” says Pagani, who encourages telephone consultations.
“We realize the importance of collaborating with our referring physicians to determine the right timing for referral to ensure the best outcome for each individual patient,” says Pagani, noting the availability of telephone consultations.
Patients are typically considered candidates for heart transplantation or an LVAD when they exhibit class III or IV heart failure symptoms and a left ventricular ejection fraction less than 35%, according to Bitar, who says approximately one-quarter of his patients are class III or IV.
Patients may also exhibit any of the following criteria for consideration of advanced treatment:
Early organ dysfunction
Hemodynamic instability (ventricular arrhythmias, hypotension or low cardiac output)
Hospitalization for heart failure in the past six months
Intolerance/withdrawal of evidence-based heart failure oral agents
Non-responsive to biventricular pacing/continuous resynchronization therapy
Candidate for or currently on inotropes
High diuretic dose (Furosemide greater than 160 mg/day, Torsemide greater than 80 mg/day and Bumetanide greater than 4 mg/day)
Seattle Heart Failure Score greater than 1.5 or one-year mortality estimate greater than 15%
Peak exercise oxygen consumption less than 55% of predicted or absolute number less than or equal to 14 ml/kg/min for women and less than or equal to 16 ml/kg/min for men
Six-Minute Walk Test distance of less than 350 meters
Print, pin or save a PDF of a visual guide to the “Markers for Advanced Heart Failure” from Michigan Medicine experts.
Establishing a relationship
“If a physician can identify early signs of heart failure progressing to advanced stages and refer them to us, we can begin evaluation and have a much better chance of treating them,” Bitar says, noting that the first line of treatment for an early-stage patient is medication.
“Our goal is to establish a relationship early on with the patient and discuss the possibility of future transplant or LVAD therapies before end-stage organ failure makes their condition irreversible,” says Bitar.
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This, Pagani believes, is critical. “It’s always better to see the patient in a non-emergent situation to discuss possible future therapies. This gives the patient and their family time to process the information.” When a patient is seen in the later stages of heart failure, their only option might be a transplant or LVAD. In this case, Pagani says, “The patient may not be ready to accept the option.”
Education and support
“Advanced heart failure therapies require significant patient education,” says Bitar. “Appropriate education and time for patient decision-making become jeopardized when patients come for emergent evaluation.”
To that end, Michigan Medicine provides LVAD education by a dedicated health care team as well as support from social workers and other LVAD patients to discuss the benefits and risks of LVAD therapy, says Pagani.
“Our team helps patients and their caregivers understand all aspects of living with an LVAD — from changing batteries and monitoring alarms to taking care of the driveline site and ensuring their home has the proper electrical outlets,” says Angela Rose, P.A.-C., of the Michigan Medicine Ventricular Assistance Device Clinic.
Social workers are available to support patients in their decision-making process, says Rose. “Patients are also provided with a comprehensive informative packet that includes the Colorado Decision Aid comparing LVAD therapy to medical management.”
Pagani also points out misconceptions surrounding advanced therapies for heart failure. “We’re seeing much better outcomes with heart transplant and LVADs. The field has changed quite a bit in the last few years, with noted improvements in patient outcomes, particularly with newer LVAD technology.”
These changes are reflected in a wider donor pool for heart transplants, better immunosuppressant drugs, better surveillance for rejection and better surveillance for cardiac allograft vasculopathy, a condition in which the blood vessels supplying the transplanted heart gradually narrow and restrict blood flow, says Bitar.
Patients who weren’t candidates a few years ago may be considered for transplant or LVAD today. And those who aren’t candidates for transplant may qualify for an LVAD as destination therapy.
LVAD technology has come a long way, Pagani says, with survival rates similar to heart transplantation in the early years following device implantation. On the horizon is a completely implantable device that can be charged through the skin, eliminating the need for a driveline. LVADs have become smaller in size with greater hemocompatibility and reduced number of related complications such as infection, bleeding and stroke.
Bitar stresses the importance of physicians being aware of these improved options for treating patients with advanced heart failure. “We want to partner with our referring physician colleagues to ensure they’re able to help their patients make informed decisions about treatment before their heart failure becomes too severe.”