Abstract & Commentary
Who Should be Referred for Advanced Heart Failure Care?
By Michael H. Crawford, MD, Editor
Source: Thorvaldsen T, et al. Triage of patients with moderate to severe heart failure: Who should be referred to a heart failure center? J Am Coll Cardiol 2014;63:661-671.
Some patients with heart failure (HF) due to systolic left ventricular (LV) dysfunction may benefit from advanced therapies such as heart transplantation, left ventricular assist devices (LVAD), or palliative care, but criteria for referring patients to advanced HF centers are lacking. Thus, these investigators from Sweden interrogated their country’s HF registry to ascertain variables that independently predict survival and can be used as triggers for referral to advanced HF care. Between 2000 and 2013, more than 10,000 patients with New York Heart Association (NYHA) class III-IV heart failure and LV ejection fraction < 40% were registered. At baseline, 46 clinically relevant variables were analyzed with regard to mortality and compared to the overall Swedish population (expected mortality) in three age groups: < 65 years (n = 2247), 66-80 years (n = 4632), and > 80 years (n = 3183). In those < 80 years, based on previous data, five risk factors for all-cause mortality were studied: systolic blood pressure < 90 mmHg, creatinine > 1.9 mg/dL, hemoglobin < 12 g/dL, absence of renin angiotensin antagonist, or absence of beta-blocker therapy. The observed and expected survival for those < 65 years was 90% vs 99%; 66-80 years was 79% vs 97%; and > 80 was 61% vs 89%. In those < 80 years, the presence of 1, 2, or 3-5 risk factors increased mortality with HRs of 1.4, 2.3, and 4.1, and 1-year survivals of 79%, 60%, and 39%, respectively. The authors concluded that more than one of these five simple risk factors for death would be an indication to explore advanced therapies in systolic HF patients < 80 years of age. Above age 80, palliative care should be considered.
The thesis of this study is that there are patients being managed by primary care doctors and perhaps cardiologists who may benefit from referral to a HF center. The authors point out that in Sweden, 50% of patients with HF are cared for by primary care doctors. They believe that the various HF scores and exercise peak VO2 are too complex for most busy practitioners to consider. Thus, they sought simple criteria for referral to a HF specialist, based on previous studies. They did not prospectively validate the risk factors they chose, but they did analyze their ability to predict all-cause mortality in a HF database. The presence of one of their five risk factors dropped 1-year survival lower than that expected with LVAD or heart transplant therapy (79% vs 80% for LVAD and 90% for transplant). The presence of more than one risk factor progressively decreased survival further. They emphasize that their risk factors are useful for deciding on referral, not selection for advanced therapy. Not all referred patients may be suitable for advanced therapies; especially those over 80 years who may be better candidates for palliative care, which is used less frequently in HF as compared to cancer. Perhaps all high-risk HF patients deserve one consultation with an advanced care specialist. Thus, in NYHA class III or IV patients with HF and EF < 40%, the presence of systolic blood pressure < 90 mmHg, creatinine > 1.9 mg/dL, hemoglobin < 12 g/dL, or the absence of ACEI/ARB or beta-blocker therapy (for whatever reason), should be referred to an advanced HF therapy center.