A doctor’s wish list for smoother CHF treatment
There is a lot of interaction between doctors who treat patients with CHF. Pull a few of these physicians aside and ask them what would make treatment run more smoothly, and you may hear suggestions such as these:
• Recognize the urgency of CHF and get the right physicians involved quickly.
"I think it’s important to realize heart failure is an extremely serious disease," says Gordon A. Ewy, MD, chief of cardiology at the University of Arizona Health Sciences Center and director of the Sarver Heart Center, both in Tucson. "Its prognosis is worse than most cancers. If you have a patient with cancer, you send the patient to a specialist," he says. "Unless you like to do heart failure cases yourself, you should do the same thing."
• Remember women’s needs.
Doctors need to make female CHF patients aware of the severity of their disease and that it should be taken very seriously, says Amparo C. Villablanca, MD, from the University of California, Davis, School of Medicine and Medical Center. Women with CHF tend to be sicker and have an outcome that is much worse than their male counterparts. But they may not realize how heart disease affects them, says Villablanca, who also is the director of the Women’s Cardiovascular Health Program and Clinic. (See related article on compliance issues, p. 8.)
There is a lack of awareness that heart disease is the No. 1 killer of women," she says, noting that only 8% to 20% of women in this country recognize it as the lead threat to women’s health.
• Don’t allow the disease to progress before you try to control it.
"It’s always nice to see the patient early enough in the disease, not only to treat the sick, but to see the patient at a state of reduced ejection fraction but no limitation yet," adds Marc Silver, MD, director of the Heart Failure Institute at Christ Hospital in Oak Lawn, IL, and author of Success with Heart Failure.
• Make sure patients are taking the right medication.
"If it were a board-certification-exam question — what class of medication has been shown to improve the condition of patients with congestive heart failure?— everyone would check off ACE inhibitors. But only 40% of people who should be taking them actually receive them," says Richard Pozen, MD, national medical director of Vivra Heart Services in Fort Lauderdale, FL, and its HeartAssist CHF disease management program. "And of these people, only half are at a dose high enough to see the benefits."
• Keep good records for you AND the next treating physician.
Note as much as you can — what’s being done, whether the disease has progressed, current medication, ejection fraction evaluations — it’s all important. "At least then you’re feeling like you’re picking up where the groundwork has been laid," Silver says.
• Get a handle on CHF comorbidities.
"You have to deal with heart failure patients in a holistic way," says Silver. That means looking for associated pulmonary diseases and also to look for the very real possibility of depression. Silver says the generalist can start treatment for these conditions, then note them for the specialist who will continue with the care.
• Educate the patient to understand the disease and what is being done to treat it.
"If the patient has an idea of the test history or an idea of the diagnostic summary and records, that’s very helpful," he says . But even before the testing, the patient should have a basic understanding of the disease, he says. In a recent study of 100 patients recently referred to him, only a third could tell him what heart failure is.
• Get your patients to follow your instructions.
"The name of the game is compliance," says Pozen. "With heart failure, the hospital readmission rate within 90 days is 50%. The reason they get readmitted is a lack of compliance to treatment."
• Stay in close communication with the referring physician.
Rick Smith, MD, a geriatrician, says that he would like cardiologists to talk with him before they order tests or prescribe medication. The medical director of the Los Angeles Jewish Home for the Aging says his average patient is 90.
Smith says that it’s a rare event to send one of his patients to a cardiologist for CHF alone. Most of the time, beside heart failure, there are arrhythmias, valvular problems, ischemic heart disease, or other conditions involved at the same time.
"I have to be so careful about drug interactions," he says. That’s why he doesn’t want the cardiologist to start treating or testing his patients until he has a chance to discuss the case with the physician directly.
Chances are good that the cardiologist will not know all the details of the drug formulary or all the tests that have been done already. A quick discussion with him at the facility or calling him while the patient is in the cardiologist’s office can prevent problems and extra stress on the patient, Smith says. And it must be the cardiologist calling in person, not the nurse, to ask if suggested treatment is OK. "What if it’s not OK?" he asks, noting he needs to be able to discuss the case with the other doctor.
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