Keith C. Ferdinand, MD, on What PCPs Should Know About Heart Failure
The burden of heart failure (HF) is high in the United States. According to the Centers for Disease Control and Prevention (CDC), about 5.7 million Americans are affected by heart failure (HF), and approximately half of HF cases result in death within 5 years post-diagnosis.1
In addition, HF is also associated with a high cost burden. In fact, CDC data indicate that healthcare costs associated with HF reach an estimated $30.7 billion per year in the United States. 1
Costs related to HF have become the leading cause of expenditures among Medicare beneficiaries, said Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA, professor of medicine at Tulane University School of Medicine in New Orleans, Louisiana, and past chair of the National Forum for Heart Disease and Stroke Prevention.
Perhaps of even greater concern is that burden of patients with HF outnumber the specialists available to treat them, said Dr Ferdinand, making it more important than ever for primary care providers to help control their patients’ risk factors for HF and to be able to recognize and treat HF early.
Consultant360 discussed HF and its primary care implications further with Dr Ferdinand, who presented “Update in the Management of Heart Failure: A Practical, Guideline-Directed Approach” on September 16 at the 2018 Cardiometabolic Risk Summit in San Antonio, Texas.2
Consultant360: In your view, what is the biggest knowledge gap in primary care when it comes to identifying and managing HF?
Keith C. Ferdinand: I think most primary care providers are aware that HF, especially in major clinical outcomes trials, is caused by coronary disease. If 40% or more of the myocardium is damaged by an acute myocardial infarction, systolic dysfunction and HF will often occur.
However, what is often underappreciated in primary care is that hypertension—or uncontrolled high blood pressure—is actually the underlying etiology in most cases of HF. While it is important to reduce lipid levels and treat persons with acute heart attacks appropriately with percutaneous coronary intervention, we must also control high blood pressure in order to stem the tide of increasing HF as our population ages.
C360: Are there any questions about HF that you feel primary care physicians are not asking you often enough, but should be asking?
KF: One of the blind spots affecting our understanding of how to best treat HF is in the area of HF with preserved ejection fraction (HFpEF). Most outcome trials for HF and practically all guideline evidence for HF is based on HF with reduced ejection fraction (HFrEF) of 40% or less.
Nevertheless, HFpEF is almost as common as HFrEF, especially among older persons and women with hypertension and diabetes. In fact, HFpEF with ejection fractions of 50% or greater may be more common in some special populations.
I call the area of HFpEF treatment a “blind spot” because at this time, we really do not have good outcome data on the best way to treat these patients. Although there is empirical evidence that supports appropriate control of blood pressure and use of diuretics at an adequate level, including more potent agents such as chlorthalidone vs hydrochlorothiazide and loop diuretics in persons with stage-3 chronic kidney disease or worse, there is really no clear evidence from outcome trials that mortality among patients with HFpEF can be reduced using any class of medicines.
C360: Why is it important to distinguish between HFpEF and HFrEF? What are the clinical implications for each category?
KF: As the population ages and diabetes becomes more common, there will likely be an increasing proportion of persons who are admitted to the hospital with obvious HF with pulmonary congestion, as well as an increase in natriuretic peptides such as B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-proBNP). Nevertheless, more and more of these patients will be noted to have HFpEF with ejection fractions greater than 50%.
Again, the reason I call the area of HFpEF a “blind spot” is because we do not have robust evidence that any particular medication can help reduce mortality in patients with HFpEF. Although available data for HFrEF has demonstrated that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers, along with evidence-based β-blockers and aldosterone antagonists ,like spironolactone, can help decrease mortality in patients with HFrEF, the same level of evidence does not yet exist for the treatment of HFpEF.
That being said, the recent spironolactone trial called Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) indicated that spironolactone use appeared to reduce hospitalizations specifically among HFpEF patients who had taken the medication as indicated by the protocol (even though it was overall a negative trial).
It is important to note that, among patients in the TOPCAT trial from Russia and Georgia who were randomly assigned to treatment with spironolactone, it appeared that as many as 30% of these participants may not have been taking the medicine at all, based on their metabolites of spironolactone. Knowing this, the participants from Russia and Georgia likely drove the negative outcomes in that trial, suggesting no benefit from spironolactone use.
However, when specifically assessing patients from North America and Europe, spironolactone use appeared to help decrease hospitalizations and mortality associated with HFpEF.
C360: What is considered appropriate disease monitoring for HF in primary care, especially with respect to diagnostic testing and treatment?
KF: Of course, controlling risk factors is one of the first things we must do. We must not only lower patients’ lipid levels, but also their high blood pressure. Blood sugar control may also be important, especially with newer agents such as empagliflozin and other sodium-glucose cotransporter-2 (SGLT-2) inhibitors. In the EMPA-REG OUTCOME trial, empagliflozin use was associated with reductions in overall cardiovascular disease and, specifically, decreased hospitalizations due to HF.
Patients with shortness of breath and any physical symptoms such as pulmonary congestion, leg edema, and increasing weight gain should be considered for a resting electrocardiogram, complete blood count, urinalysis, and comprehensive metabolic profile to determine whether their BNP or NT-proBNP levels are elevated. The clinical use of these particular biomarkers is a sign of our progress regarding our ability to diagnose HF before a patient requires hospitalization for flagrant pulmonary edema.
C360: When should primary care physicians consult or refer to a specialist?
KF: There are not enough specialists to control HF in the general population. Therefore, primary care providers- including physicians, nurse practitioners, and physicians’ assistants- will be increasingly called upon to identify and appropriately treat patients with HF.
The specific diagnosis of HFrEF vs HFpEF can be determined by an echocardiogram. Imaging or invasive studies for myocardial ischemia are not necessary unless a patient is overtly symptomatic for coronary artery disease. With this in mind, perhaps the most important steps that primary care providers can take are controlling their patients’ risk factors and making the early diagnosis of HF before hospitalization, along with blood pressure control and appropriate diuretic use.
In patients with HFrEF, modulating agents—including renin angiotensin system modulating agents like ACE inhibitors, angiotensin receptor blockers, and evidence-based β-blockers—are particularly important to reduce hospitalizations and overall mortality.
Of course, patients who have been admitted to an intensive care unit should receive appropriate care by a cardiologist for a potentially life-threatening condition. There are outcome studies which have demonstrated that intensive-care patients with HF who receive their primary care from a cardiologist often have improved outcomes and decreased re-hospitalizations.
C360: What factors affect treatment adherence in patients with HF, and what strategies could primary care providers implement in their own practice to help increase adherence?
KF: There are numerous complicated reasons that patients do not adhere to treatment. Adherence is often affected by socioeconomic status, limited English proficiency, low health literacy, lack of family or social support, and cost of care.
As physicians and other providers, the most important thing we can do is educate our patients to become partners in their care. Patients with HF often need to take 5 or 6 medications, which can be a daunting task. Physicians and other providers who treat patients with HF need to sit down with them at eye-level and speak to them in a culturally-appropriate and literacy level-appropriate manner using models, diagrams, and figures. Then, to ensure complete understanding, providers should have their patients teach back to them what they have just been taught.
Allow your patients to ask questions. Although many busy practitioners feel that this is an intrusion on the increasingly shortened period of time they have to care for their patients, most patients are satisfied with face-to-face answered questions and education of no more than 1 to 2 minutes.
Currently, HF is the number one cause of expenditures in the Medicare population. Informed and educated patients become partners in their care, which can hopefully decrease readmissions and costs for HF, especially after a hospitalization with an appropriate 7- to 10-day follow-up.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA, is a professor of medicine at Tulane University School of Medicine in New Orleans, Louisiana, and a past chair of the National Forum for Heart Disease and Stroke Prevention.
—Christina Vogt
References:
1. Heart failure fact sheet. Centers for Disease Control and Prevention: Division for Heart Disease and Stroke Prevention. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm. Accessed on September 10, 2018.
2. Ferdinand KC. Update in the management of heart failure: A practical, guideline-directed approach. Presented at: 2018 Cardiometabolic Risk Summit; September 14-16, 2018; San Antonio, TX.