VIEWPOINTS
The evolving challenge of chronic heart failure management
A call for a new curriculum for training heart failure specialists
Philip B. Adamson, MD, FACC*,*,
William T. Abraham, MD, FACC ,
Charles Love, MD, FACC and
Dwight Reynolds, MD, FACC*
* Department of Medicine, Cardiovascular Diseases Section, Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Department of Medicine, Division of Cardiovascular Medicine, Department of Physiology, The Ohio State University, Columbus, Ohio
Manuscript received March 17, 2004;
revised manuscript received April 16, 2004,
accepted April 27, 2004.
* Reprint requests and correspondence: Dr. Philip B. Adamson, Department of Medicine, Cardiovascular Disease, 920 S. L. Young Boulevard, WP3120, Oklahoma City, Oklahoma 73104 (Email: Philip-adamson{at}ouhsc.edu).
 |
Abstract
|
|---|
Chronic heart failure (HF) is a growing epidemic, and therapy options are becoming more complex. Specifically, device management of HF represents a new "class" of therapy that can reduce mortality and alleviate morbidity of the disease syndrome. Heart failure training programs seldom provide structured opportunities for trainees to gain competence in device implantation and management. This curriculum outlines a new approach to training interventional HF cardiologists and internal medicine HF specialists to meet the growing demands for specially trained health care providers.
|
Abbreviations and Acronyms
| | HF = heart failure | | NASPE/HRS = North American Society of Pacing and Electrophysiology/Heart Rhythm Society |
|
Over the last 30 years, an evidence base that furthers our understanding of the mechanisms of mortality and morbidity associated with chronic left ventricular dysfunction has emerged (1–3). Subsequently, medical and device therapies are now available that reduce symptoms, reverse progression of left ventricular dysfunction, and, importantly, improve long-term survival without the need for heart transplantation (1–10). Just 30 years ago, the hope for survival in patients with heart failure (HF) was dismal and centered on transplantation as the ultimate therapy (11). Consequently, it is not surprising that most cardiologists with specific training in treating HF patients have had an emphasis on transplant-related medical care. In fact, while specific training requirements and a certification process exist for transplant cardiology (12), there are no published criteria describing acceptable training as a HF specialist. The realities of transplant organ availability, age at the time of transplant evaluation, and comorbidities make heart transplantation an epidemiologically insignificant intervention available to only a few HF patients. In fact, almost 80% of HF patients are over the age of 65 years (13). Most patients with HF will never be candidates for heart transplantation. The historic coupling of specialized HF management training with the limited opportunities one encounters in transplant cardiology may have unwittingly slowed important growth in the numbers of HF specialists.
Specialized training programs for HF management are increasing because more complicated treatment modalities are required, as well as available, to achieve favorable clinical outcomes without relying on protracted and expensive in-hospital management (13–16). Specialized treatment centers that provide frequent follow-up and organized delivery of standard of care therapy, for example, have a dramatic impact on hospital use, re-admissions, and length of hospital stay (14–16). Most HF specialty treatment centers create a multidisciplinary team of providers that includes cardiologists who have a special interest or training in HF management and non-physician providers who follow algorithms to frequently evaluate patients and adjust their long-term medical therapy. The success of specialized treatment centers underscores the importance of applying standard of care medical therapy and demonstrates that patients with HF indeed have hope for a reduction of symptoms and enhanced survival. It also demonstrates that managing a large number of HF patients can be quite labor intensive and complicated. This makes it more difficult to achieve the results of specialty treatment centers in general cardiology or internal medicine practice settings.
To further complicate HF management, recently a new "class" of therapy for HF patients has emerged. In addition to maximal medical care (i.e., drug therapy), devices intended to prevent sudden cardiac death (implantable cardioverter-defibrillators [10]) and cardiac resynchronization devices (biventricular pacemakers [4–9]) reduce morbidity and mortality in appropriate patient populations. Devices under investigation for the treatment of HF include percutaneously applied ventricular assist devices, ultrafiltration, implantable hemodynamic monitoring systems, and others. For example, implanted monitoring systems provide continuous cardiovascular physiologic data that are still experimental, but promise to guide medical management and reduce episodes of severe decompensation in high-risk patients (17–19). As our understanding of opportunities with this new therapeutic class develops, new applications of device therapy in HF are emerging, creating substantially larger groups of patients in whom device therapy is appropriate. Although this is exciting and provides hope for a further reduction of HF morbidity and mortality, it may strain the available workforce qualified to implant devices. General cardiologists implant and follow most pacemakers, whereas most of the implantations and virtually all of the follow-up of implantable cardioverter-defibrillators are the responsibility of electrophysiologists. Electrophysiologists or cardiologists with higher volume pacemaker implant experience usually perform biventricular pacemaker system implantations aimed at cardiac resynchronization therapy. The dramatic increase in the number of implants, along with the expected epidemic of HF patients in the next 30 years, makes it clear that there is a need for larger numbers of providers that are competent in implanting the devices designed for patients with HF. Furthermore, currently an artificial and inefficient disconnect exists between implanting physicians and HF specialists. Many times, implanting physicians do not have specialized training or interest in HF management, and HF physicians do not have specialized training in implant procedures or long-term device management. Coupling an understanding of device therapy, including implantation techniques for some, with competence in HF management and pathophysiology will serve to further advance this very important and growing part of cardiovascular disease management.
Although non-cardiologist providers currently treat most HF patients, several studies demonstrate that specialist care is more likely to conform to consensus standards and produces better outcomes in HF (20–22). This suggests that current training programs for primary care providers (internal medicine and family practice) may not be delivering an adequate understanding of life-saving medical based therapeutic interventions. Device therapies are, then, another layer of complexity in which primary providers do not have expertise as a result of their training programs. That is not to say that primary care providers cannot learn the intricacies of chronic HF management, but specific training programs will be required to establish clinical competency. In the growing epidemic of HF, having more providers who have specialty training will only help deliver standards of care that will meet patients' needs in a cost-efficient manner.
This paper outlines a new curriculum, instituted at the University of Oklahoma Health Sciences Center and in a modified form at the Ohio State University, for training of interventional HF cardiologists and for training internists in HF management. The programs are designed to increase specially trained individuals with competency in the spectrum of complex HF management. We suggest that this pilot curriculum may provide the basis for a successful strategy to provide specially trained providers equipped to manage the growing epidemic of patients with HF. In the future, evaluation methods such as certification of special competency may be required to ensure that providers have appropriate training and clinical experience to treat this very important disease process.
The curriculum suggested calls for cardiovascular disease fellows to complete two years of general cardiology training followed by two years of training in HF management (Table 1). The general cardiology training portion of the HF fellowship conforms to requirements enunciated in accreditation and certification standards for general cardiology (12). In the third year of fellowship, HF training will consist of dedicated management of HF, including administration and supervision of inpatient and outpatient HF treatment programs. The fellow will gain expertise in advanced competency in echocardiography (23), as well as comprehensive medical management of the disease. The second year of training will ensure competency in device implantation and management. The device curriculum requirements will comply with guidelines outlined by the North American Society of Pacing and Electrophysiology/Heart Rhythm Society (NASPE-HRS) (24), including any updated training requirements published in the future. Training will be required to establish both cognitive and technical competency to implant cardiac defibrillators, pacemakers, and biventricular devices. Specific training in the future use of new devices, such as implantable hemodynamic monitoring systems, will be provided by this curriculum.
View this table:
[in this window]
[in a new window]
|
Table 1. Summary of Recommended Goals of Two-Year Interventional Heart Failure Fellowship Program Designed to Start After the First Two Years of General Cardiology Training
|
|
General internal medicine-trained physicians will enter the training program for one year, following internal medicine residency, and will gain competency in medical management of HF coupled with level 1 competency in echocardiography (Table 2). Although exposure to device therapy is included and important in the curriculum for general internists, device implant training is not part of the curriculum. Device management would remain the direct responsibility of those specialists trained comprehensively in this area. On the other hand, especially in the non-"electrophysiologic" aspects of device therapy, such as telemetric monitoring functions, it will be important for the specially trained internists to have substantial training. The goals will be to train a provider that can competently maximize drug therapy to reduce the need for hospitalizations, while improving survival and quality of life.
View this table:
[in this window]
[in a new window]
|
Table 2. Summary of Suggested Training Goals for Internal Medicine-Trained Physicians Eligible for ABIM Specialty Board Examination
|
|
We feel strongly that the interventional HF cardiologist and the HF internist will bolster the workforce available for patients with chronic HF and, hopefully, will create a group of specialists with specific clinical competency to complement those who traditionally have implanted and managed device therapy. The proposed fellowship programs would provide the interventional HF specialist with competency in a "niche" procedural skill without prolonging overall training time. This may make HF specialization training more attractive to applicants also considering interventional cardiology or electrophysiology.
In the future, HF management will very likely involve more devices for therapy and monitoring. In that spirit, we submit the suggested training goals for HF specialty fellowship. If a thoughtful approach to meet the needs of the upcoming HF epidemic is not entertained, our health care system is destined to provide substandard, cost-inefficient care, and many patients will continue to miss the benefit of life-saving interventions, including device management.
|
References
|
|---|
1. Bristow M. Antiadrenergic therapy of chronic heart failure: surprises and new opportunities Circulation 2003;107:1100-1102.[Free Full Text]
2. Braunwald EB, Bristow MR. Congestive heart failure: fifty years of progress Circulation 2000;102:14-23.[Abstract/Free Full Text]
3. Packer M. The neurohormonal hypothesis: a theory to explain the mechanism of disease progression in heart failure J Am Coll Cardiol 1992;20:248-254.[Abstract]
4. Cazeau S, Leclercq C, Lavergne T, et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay N Engl J Med 2001;344:873-880.[Abstract/Free Full Text]
5. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure N Engl J Med 2002;346:1845-1853.[Abstract/Free Full Text]
6. St. John Sutton M, Plappert T, Abraham WT, et al. Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure Circulation 2003;107:1985-1990.[Abstract/Free Full Text]
7. Adamson PB, Abraham WT. Cardiac resynchronization therapy for advanced heart failure Curr Treat Options Cardiovasc Med 2003;5:301-309.
8. Saxon LA, Ellenbogen KA. Resynchronization therapy for the treatment of heart failure Circulation 2003;108:1044-1048.[Free Full Text]
9. Bradley DJ, Bradley EA, Baughman KL, et al. Cardiac resynchronization and death from progressive heart failure: a meta-analysis of randomized controlled trials JAMA 2003;289:730-740.[Abstract/Free Full Text]
10. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction N Engl J Med 2002;346:877-883.[Abstract/Free Full Text]
11. McKee PA, Castelli WP, McNamara PM, et al. The natural history of congestive heart failure: the Framingham experience N Engl J Med 1971;285:1441-1445.[Medline]
12. Beller GA, Bonow RO, Fuster V. Core Cardiology Training Symposium (COCATS): ACC revised recommendation for training in adult cardiovascular medicineCore Cardiology Training II (COCATS 2). Revision of the 1995 COCATS Training Statement. J Am Coll Cardiol 2002;39:1242-1246.[Free Full Text]
13. Rich MW. Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults J Am Geriatr Soc 1997;45:968-975.[Medline]
14. Fonarow G, Stevenson LW, Walden JA, et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure J Am Coll Cardiol 1997;30:725-732.[Abstract]
15. Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure N Engl J Med 1995;333:1190-1195.[Abstract/Free Full Text]
16. Hanumanthu S, Butler J, Chomsky D, et al. Effect of a heart failure program on hospitalization frequency and exercise tolerance Circulation 1997;96:2842-2848.[Abstract/Free Full Text]
17. Adamson PB, Magalski A, Braunschweig F, et al. Ongoing right ventricular hemodynamics heart failure: clinical value of measurements derived from an implantable monitoring system J Am Coll Cardiol 2003;41:563-567.
18. Adamson PB, Kleckner K, VanHout WL, et al. Cardiac resynchronization therapy improves heart rate variability in patients with symptomatic heart failure Circulation 2003;108:266-269.[Abstract/Free Full Text]
19. Magalski A, Adamson PB, Gadler F, et al. Continuous ambulatory right heart pressure measurements with an implantable hemodynamic monitor: 12-month follow-up in a multi-center trial of chronic heart failure patients J Card Fail 2002;8:63-70.[CrossRef][Medline]
20. Rutten FH, Grobbee DE, Hoes AW. Differences between general practitioners and cardiologists in diagnosis and management of heart failure: a survey in every-day practice Eur J Heart Fail 2003;5:337-344.[Abstract/Free Full Text]
21. Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting J Am Coll Cardiol 2003;41:69-72.[Free Full Text]
22. Reis SE, Holubkov R, Edmundowicz D, et al. Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes J Am Coll Cardiol 1997;30:733-738.[Abstract]
23. Quinones MA, Douglas PS, Foster E, et al. American College of Cardiology/American Heart Association clinical competence statement on echocardiograph: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence Circulation 2003;107:1068-1089.[Free Full Text]
24. Hayes DL, Naccarelli GV, Furman S, et al. NASPE training requirements for cardiac implantable electronic devices: selection, implantation, and follow-up Pacing Clin Electrophysiol 2003;26:1556-1562.[CrossRef][Medline]
This article has been cited by other articles:
|
|
|
|
 
B. L. Wilkoff, K. T. Ousdigian, L. D. Sterns, Z. J. Wang, R. D. Wilson, J. M. Morgan, and for the EMPIRIC Trial Investigators
A Comparison of Empiric to Physician-Tailored Programming of Implantable Cardioverter-Defibrillators: Results From the Prospective Randomized Multicenter EMPIRIC Trial
J. Am. Coll. Cardiol.,
July 18, 2006;
48(2):
330 - 339.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. Aranda Jr, G. W. Woo, R. S. Schofield, E. M. Handberg, J. A. Hill, A. B. Curtis, S. F. Sears, J. S. Goff, D. F. Pauly, and J. B. Conti
Management of Heart Failure After Cardiac Resynchronization Therapy: Integrating Advanced Heart Failure Treatment With Optimal Device Function
J. Am. Coll. Cardiol.,
December 20, 2005;
46(12):
2193 - 2198.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. B. Adamson, W. T. Abraham, C. Love, and D. Reynolds
Reply
J. Am. Coll. Cardiol.,
June 21, 2005;
45(12):
2098 - 2098.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Ahmed
Heart Failure Training: Care for Older Adults With Chronic Heart Failure
J. Am. Coll. Cardiol.,
June 21, 2005;
45(12):
2096 - 2097.
[Full Text]
[PDF]
|
|
|
|
Top
Abstract
References