GRAPEVINE, TX — A third of patients admitted with acute heart failure with preserved ejection fraction (HFpEF) were assigned to care by generalist physicians, and a cardiology consult was sought in only a few of those cases, in a retrospective analysis covering a recent 4 months at a major academic tertiary-care center[1].
Moreover, HFpEF patients admitted to a generalist team were more likely to be rehospitalized within a week of discharge, compared with those assigned to the cardiology service.
“Patients cared for by cardiologists received much higher doses of diuretic during their time in the hospital and at time of discharge,” Dr Caitlin S Drescher (Brigham and Women’s Hospital, Boston, MA) told theheart.org | Medscape Cardiology.
“So I think cardiologists are little bit more aggressive with their diuretic strategy, and that may contribute to being able to keep patients out of the hospital longer.”
On the other hand, those who went to generalists were more likely to have comorbidities that complicated their presentation, such as diabetes or chronic obstructive pulmonary disease (COPD), that might have swayed which clinician team managed their care.
Baseline Features of Patients Hospitalized With HFpEF, by Admitting Service
| End points | General medicine, n=50 (%) | Cardiology/heart failure, n=101 (%) | P |
|---|---|---|---|
| White | 46 | 72.3 | 0.002 |
| Atrial fibrillation | 44 | 67.3 | 0.006 |
| Valve disease | 26 | 47.5 | 0.011 |
| Diabetes | 60 | 43.6 | 0.057 |
| COPD | 48 | 29.7 | 0.027 |
COPD=chronic obstructive pulmonary disease
“If it’s more equivocal, they’re more likely to go to a generalist,” she said. That’s possible even when it’s clearly a heart-failure exacerbation but the patient is “medically complicated,” said Drescher, who presented the analysis at the Heart Failure Society of America 2017 Scientific Meeting.
For example, “if they also have difficult-to-manage diabetes or recently had pneumonia, that may also tip the scales to send a patient to a generalist service instead of a cardiologist.”
Similarly in the study, patients who went to the cardiology service were more likely to have atrial fibrillation or valve disease that may have boosted their chances of going to the cardiology service, she said.
The findings are consistent with published data going back more than a decade, in broader populations with acute heart failure, including analyses from Canada and the US[2]. The latter saw significantly fewer 6-month rehospitalizations with cardiologist hospital care, but there wasn’t a similar effect on 6-month mortality.
Based on national statistics, “it appears that patients with preserved-EF heart failure are very often managed by noncardiologists. This speaks in some ways to changing management in hospitals, where hospitalist-driven evaluation and management has grown,” Dr James L Januzzi Jr (Massachusetts General Hospital, Boston) said in an interview.
“Cardiology, at many if not most medical centers, simply doesn’t have the capacity to manage every single patient in the house with heart failure.”
But he agreed that “patients managed by cardiologists are going to be more likely assessed and managed in a more aggressive fashion.” In the analysis, that’s apparent from their greater use of diuretics “as well as use of cardiac catheterization, presumably right-heart catheterization, during hospitalization.” Januzzi isn’t connected with the current analysis.
“Perhaps the most important result of this study is the fact that patients managed by cardiology were more likely to demonstrate continuity of care,” he said, pointing the much greater likelihood that such patients would have a cardiology appointment within 7 days of discharge. “This more likely than not explains the reduced short-term rehospitalization and mortality.”
Drescher agreed. “Having that kind of short-term follow-up outside of the hospital to make sure everything is going kind of as planned and whether any further adjustments need to be made at that time—that someone is seeing the patient and making those adjustments—I think that probably plays quite a large role in keeping patients out of the hospital.”
In-Hospital and Discharge Management in Patients Hospitalized with HFpEF, by Admitting Service
| End points | General medicine, n=50 (%) | Cardiology/heart failure, n=101 (%) | P |
|---|---|---|---|
| Cardiac catheterization during stay (%) | 4 | 18.8 | 0.013 |
| Discharge diuretic dose (mg furosemide equivalent) | 152 | 267.1 | 0.017 |
| Outpatient cardiologist appointed (%) | 49 | 86.1 | <0.001 |
| Cardiology appointment within 7 days of discharge (%) | 4 | 18.8 | 0.013 |
| Cardiology appointment within 14 days of discharge (%) | 12 | 34.7 | 0.003 |
More broadly, the findings “indicate how a cross-disciplinary collaboration between cardiologists and noncardiologists can optimally manage these patients and is so necessary,” according to Januzzi.
“It might very well have the general medicine person as the quarterback of the team but might involve the consultative input of a specialist for the various medical conditions these patients seem to have,” he said. “Knowing when and why a cardiologist should get involved is definitely something that we can all work on together.”
Of 294 HF admissions at Drescher’s center in the analysis, 145 had reduced-EF heart failure (HFrEF). Of those, 86.2% went to cardiology team and 13.8% to generalist team. Of the latter group, 40% had a cardiology consult.
In contrast, 33.1% of those with HFpEF, meaning they had an ejection fraction >40%, were assigned to a generalist service. Only 12% had a cardiology consult, and only half were followed by a cardiologist as outpatients.
Outcomes of Patients Hospitalized with HFpEF, by Admitting Service
| Postdischarge HF readmission or death from any cause | General medicine, n=50 (%) | Cardiology/heart failure, n=101 (%) | P |
|---|---|---|---|
| At 7 d* | 16 | 5.0 | 0.023 |
| At 30 d | 32 | 23.8 | 0.280 |
*No deaths
Both Drescher and Januzzi wondered, given that the current data are from a nationally recognized academic referral center, what the picture is like nationally, especially at smaller hospitals.
“It’s reasonable to expect that these findings would be different at a nonacademic medical center, although it remains to be seen exactly how that would be,” Januzzi said.
Her center’s 30-day readmission numbers are “near the national average. We are a tertiary center, so we tend to have sicker patients and more complex, more serious comorbidities among our heart-failure population,” Drescher said.
On the other hand, “We are lucky to have a lot of expertise in the physicians at the Brigham and a lot of resources at our disposal. So I’m not sure how different these data would be at a community hospital, at a less resource-rich hospital system.”
That’s one of the next steps for this research, she said.
Drescher had no relevant financial relationships. Januzzi said he has no relevant financial relationships.
Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.
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