Top Things to Know: Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure
Published: September 10, 2021
Prepared by Paul St. Laurent, DNP, RN, Sr. Science and Medicine Advisor, Lead
- Advanced (stage D) heart failure (HF) is defined by severe signs and/or symptoms of HF at rest, intolerance to guideline-directed medical therapy (GDMT), and/or refractory symptoms or recurrent hospitalizations despite maximally tolerated medical therapy. It is a condition where conventional therapies offer inadequate quality or duration of life thus referral to an advanced HF specialist or center to access “advanced therapies”, i.e., a durable left ventricular assist device (LVAD) or heart transplantation (HT), and multidisciplinary care may be beneficial.
- Advanced HF centers (AHFCs) are medical centers with board-certified advanced HF and transplant cardiologists and surgeons who work with multidisciplinary teams and where both HT and LVADs are available as therapeutic options for patients with advanced HF.
- The multidisciplinary aspects of a HF disease management program available at an AHFC offer additional reasons for referral beyond consideration of advanced therapies, including optimization of GDMT, expert assessment of etiology and prognosis, access to specialized pharmacological and device therapies and clinical trials, and input by palliative care specialists.
- Clinicians caring for patients with HF should learn to recognize signs and symptoms of when patients are failing medical/device therapies and progressing to advanced (stage D) heart failure. Once patients are determined to have advanced HF, their goals-of-care should be established and documented to help educate them on which interventions may be in line with their goals and values.
- There is a two-step framework to triage patients for referral for consideration of advanced therapies; Step 1: At each encounter, clinicians should assess for clinical clues to determine whether a patient with HF is approaching or has progressed to an advanced state; Step 2: Once patients are classified as approaching or having advanced HF, clinicians should assess the likelihood of whether they would benefit from referral to an AHFC considering goals-of-care and competing risks from advanced, non-cardiac conditions.
- The optimal “Golden Window” for referral for an evaluation for advanced HF therapies (i.e., HT/LVAD) is when the severity of illness is consistent with advanced HF, but irreversible end-organ has not yet occurred, and the patient is not in extremis. In particular, late referral exposes the risk of progressive end-organ damage which increases the risk of any subsequent attempted intervention, among other deleterious consequences.
- Clinicians outside an AHFC should take steps for their patients with HF that both promote clinical stability and prepare patients in case an evaluation for advanced therapies becomes necessary. This includes educating patients that nonadherence with medical appointments and the prescribed medication regimen, ongoing use or abuse of illicit substances, or tobacco use (for HT) not only can make their condition worse but also delay their candidacy for advanced therapies.
- Clinicians must learn to recognize implicit biases and structural racism that can lead to delayed referral or non-referral due to perceptions of nonadherence. The implementation of strategies to mitigate these biases to avoid inequities in special populations, including women and race-ethnic minority patients with HF who are more likely to be referred late, are important for clinicians and health systems.
- Access to an AHFC can be extended to more patients and referring centers through shared-care models or visits via telemedicine. Collaborative care between health systems can improve patient access to advanced HF therapies.
- Processes are needed within health systems to improve recognition of advanced HF and to increase access to these potentially lifesaving therapies. These include enhanced patient engagement, screening tools to assist in assessment of prognosis, and health system-wide initiatives to capture patients with high-risk features including recurrent hospitalizations.
Citation
Morris AA, Khazanie P, Drazner MH, Albert NM, Breathett K, Cooper LB, Eisen HJ, O’Gara P, Russell SD; on behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; and Council on Hypertension. Guidance for timely and appropriate referral of patients with advanced heart failure: a scientific statement from the American Heart Association [published online ahead of print September 10, 2021]. Circulation. doi: 10.1161/CIR.0000000000001016