Optimizing Heart Failure Management - Episode 2
Dr Nasrien Ibrahim explains when primary care physicians and cardiologists should make referrals to help patients with heart failure in order to prevent advanced disease.
James Januzzi, MD: Now, let’s unfortunately ground ourselves in the real world, recognizing that heart failure is one of the most, if not the most, rapidly growing diagnoses among elderly individuals in the United States. Nasrien, we’ve talked about this, clinically speaking, about your emotions around referrals that you get as a transplanter. Share your thoughts if you would about, at what point do you feel that primary care doctors or even general cardiologists who care for a substantial percentage of patients with heart failure, at what point should those individuals refer patients to a heart failure specialist?
Nasrien E. Ibrahim, MD: Thanks for asking that question because I always say the earlier the better. There’s this optimal window for when patients are considered good candidates for transplant, and we really don’t want to miss that window. I say, I wish I would have gotten this referral earlier because maybe now the patient has multiple end-organ dysfunction, and they’re no longer a transplant candidate. There’s a really useful mnemonic called I-NEED-HELP. That is very useful for nonheart failure specialists and gives them a sense of when to refer patients for advanced therapies. But I would say things like when you admit a patient and you’re needing to put them on inotrope to help with diuresis, that’s a big indicator that a patient needs an advanced heart failure doctor. Or you’re noticing that they’re not tolerating guideline-directed medical therapies [GDMTs], that they’re too hypotensive, or that you’re having to fall back and reduce doses of GDMT.
Also, sometimes the patient cases are complicated. They have several comorbidities and now it might be a little more intimidating with 4 classes of GDMT. And if you just need help in optimizing those medications, we’re happy to help. If you’re concerned about an infiltrative cardiomyopathy or a patient who’s having several defibrillator shocks, those are the types of patients we’d like to see. The earlier the better, because even if we see patients and we’re able to optimize their guideline-directed medical therapies, and they’re not yet at a point where they need transplant or a VAD [ventricular assist device], we can always send them back and have them follow up with you regularly. We can see them again in the clinic if they ever reached the point where they would need us again. But I think not tolerating guideline-directed medical therapies is a huge indicator that a patient might be in trouble.
James Januzzi, MD: That’s such a very important message, that waiting until you’re past that golden window, which is how the American Heart Association refers to it, for a referral is such a missed opportunity.
This transcript has been edited for clarity.