Jared J Herr1, Ashwin Ravichandran2, Farooq H Sheikh3, Anuradha Lala4, Christopher V Chien5, Stephanie Hsiao6, Ajay Srivastava7, Dawn Pedrotty8, Jennifer Nowaczyk7, Shannon Tompkins2, Sara Ahmed3, Fei Xiang9, Stephen Forest10, Michael Z Tong11, Benjamin D'souza8. 1. Sutter Health CPMC Center for Advanced Heart Failure Therapies, California Pacific Medical Center, San Francisco, California. Electronic address: herrjj@sutterhealth.org. 2. St. Vincent Heart Center of Indiana, Indianapolis, Indiana. 3. MedStar Heart and Vascular Institute, Georgetown University, Washington, DC. 4. Department of Population Health Science and Policy, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. 5. Division of Cardiology, University of North Carolina, Durham, North Carolina. 6. Sutter Health CPMC Center for Advanced Heart Failure Therapies, California Pacific Medical Center, San Francisco, California. 7. Section of Advanced Heart Failure, Department of Cardiology, Scripps Clinic, San Diego, California. 8. Department of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. 9. Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China. 10. Department of Cardiothoracic Surgery, Montefiore Medical Center, New York, New York. 11. Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Abstract
BACKGROUND: Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers. METHODS: We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients' demographics, referring providers' characteristics, referral circumstances, and evaluation outcomes were collected. RESULTS: The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1-3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly, AHF therapies were not offered because patients were too sick (38.0%-45.1%) or for psychosocial reasons (20.3%-28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy, and 14.5% were referred to hospice. CONCLUSIONS: In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.
BACKGROUND: Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers. METHODS: We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients' demographics, referring providers' characteristics, referral circumstances, and evaluation outcomes were collected. RESULTS: The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1-3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly, AHF therapies were not offered because patients were too sick (38.0%-45.1%) or for psychosocial reasons (20.3%-28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy, and 14.5% were referred to hospice. CONCLUSIONS: In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.
Authors: Imo A Ebong; Ersilia M DeFilippis; Eman A Hamad; Eileen M Hsich; Varinder K Randhawa; Filio Billia; Mahwash Kassi; Anju Bhardwaj; Mirnela Byku; Mrudala R Munagala; Roopa A Rao; Amy E Hackmann; Claudia G Gidea; Teresa DeMarco; Shelley A Hall Journal: Front Cardiovasc Med Date: 2022-07-11