Advanced heart failure complexities and when to refer for specialty care

Dec. 08, 2020

Daniel S. Yip, M.D., a transplant cardiologist at Mayo Clinic's campus in Jacksonville, Florida, responds to questions about challenges in pinpointing a patient's heart failure status and when cardiologists might consider referral for advanced heart failure care.

Is it difficult to determine exact prognosis for patients with heart failure?

Yes, prognosis can be challenging because the clinical course of heart failure can be dynamic: It can have dips and plateaus, but overall trajectory is downward. Some patients can be stable for long periods of time and then slowly deteriorate. There are others whose course is one of rapid deterioration. Patients who have been hospitalized for heart failure are of particular concern. Unfortunately, approximately half of patients who have been hospitalized for heart failure will die or be readmitted within 6 months.

It is common to use left ventricular ejection fraction as a way to determine prognosis. We have found this is not always the best way to determine prognosis in patients with heart failure. There are individuals who have very poor ejection fractions who are asymptomatic and living very vigorous lives. You would not be able to guess they have heart disease. Conversely, there are individuals with better ejection fractions who are very symptomatic with even minimal activity.

Any tips for determining progression of a patient's heart failure?

The gold standard to determine prognosis in patients with heart failure is a cardiopulmonary exercise test. If this is not readily available, doing a simple six-minute walk is a powerful test that could be used to determine prognosis. These tests could be done serially to help track patient progression and prognosis over time.

Must patients be optimally treated to be evaluated properly?

Optimally treated is in the eye of the beholder. If a patient continues to have symptoms despite a provider's best efforts, then it may be in the patient's best interest to be referred for advanced heart failure care.

What are the referral criteria?

The following are some common indicators for referring to an advanced heart failure center:

  • Left ventricular ejection fraction less than 35%
  • New York Heart Association Class III-IV functional status
  • Two or more hospital admissions in the last year
  • Increased left ventricular end-diastolic dimension (6.5 cm or greater)
  • Reduced tolerance or inability to uptitrate ACE inhibitors, beta blockers
  • Consistently low blood pressure with systolic pressure of less than 100 mm Hg
  • Intravenous inotropes
  • Increased diuretic requirements or persistent edema
  • Reduced end-organ perfusion (renal function, hepatic function)

We believe inability to titrate guideline-directed therapies, such as ACE inhibitors, ARBs, ARNIs and beta blockers, to target doses or needing to decrease doses of these medications due to low blood pressure or symptoms is a powerful indicator the patient would benefit from advanced heart failure care. Readmission within 6 months is also a strong indicator the patient is at increased risk for adverse outcomes and should be considered for advanced heart failure care.

What's the ideal timing for referral?

Expeditious referral is best for patient outcomes. I believe there is no such thing as being referred too early to an advanced heart failure center. An "early" referral will allow for a discussion to review what has transpired thus far, what should be done now and what the patient can expect for the future. Unfortunately, patients who are referred too late often have very limited options.

Patients will benefit from being seen in an advanced heart failure center. While there, they will be seen by a multidisciplinary team of heart failure specialists who will design an individualized treatment plan. Also, a determination will be made about whether or not the patient would benefit from advanced heart failure therapies such as mechanical circulatory support or transplant. Patients who do not need these advanced heart failure therapies are monitored for progression. If there is a change in their prognoses, a continued relationship can lead to optimal timing for advanced heart failure therapies.

How might referring patients benefit my practice?

A segment of the heart failure population does not respond appropriately to guideline-directed therapies. These patients often require frequent office visits and rehospitalizations, which are often resource-intense interactions. We want to partner with our referring physicians. Advanced heart failure centers can provide comprehensive individualized treatment plans that will help reduce office visits and hospitalizations and improve outcomes, leading to decreased burden for referring physicians and their staff.

How have your patients fared with advanced heart failure therapies, such as mechanical assist devices and heart transplant?

We've done very well with patient outcomes. We are meeting or exceeding one- and three-year median survival for heart transplant. Our survival after ventricular assist device implant has also been very good when compared to national benchmarks.

What is your preferred method for referring a patient?

Call the Mayo Clinic Referring Provider Office. You may explain your needs to the physician liaison taking your call or request to speak to a specific physician.