CORRESPONDENCE: LETTER TO THE EDITOR
Heart Failure Training: Care for Older Adults With Chronic Heart Failure
Ali Ahmed, MD, MPH, FACC*
* Division of Geriatric Medicine and Geriatric Heart Failure Clinic, University of Alabama at Birmingham, 1530 3rd Avenue South, CH19-219, Birmingham, AL 35294-2041 (Email: aahmed{at}uab.edu).
Studies by Adamson et al. (1) and Konstam (2) eloquently highlight the need for heart failure (HF) specialists. As drug and device therapies for HF are rapidly evolving, it is difficult even for cardiologists to stay abreast of. Internists, family physicians, and geriatricians, who treat the vast majority of HF patients, often underutilize angiotensin-converting enzyme (ACE) inhibitors or beta-blockers (3). Over 80% of HF patients are 65 years of age and older (4); they are often women, have preserved systolic function, suffer from multiple comorbidities, and receive care in nonacademic settings.
The quality of primary care provided by cardiologists is unknown (5). Yet, a 35-year-old young man with systolic HF and no other comorbidities might receive optimum total care from a general cardiologist. However, a 75-year-old woman with HF and multiple comorbidities might benefit more if cared for by a primary care physician in collaboration with a cardiologist. Treatment of older adults is particularly the most complicated. For example, an elderly HF patient might receive the best HF care from a cardiologist, yet an undiagnosed or untreated osteoarthritis or depression might compromise her quality of life.
Given the HF epidemic, it is not possible for cardiologists to provide total care to HF patients. It is unlikely that training HF specialists will improve the quality of care or quality of life of these patients. A complementary approach might be: 1) building alliances with national organizations for primary care physicians to develop innovative strategies to educate these physicians about the advances in the pharmacological management of HF, and 2) encouraging policies that would reward hospitals and clinicians who follow HF quality indicators similar to those developed by the Centers for Medicare and Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations (6). Primary care physicians are capable of evaluating left ventricular function and prescribing ACE inhibitors and beta-blockers to eligible patients with systolic dysfunction. However, patients should be referred to cardiologists, at least once during the initial evaluation, for assessment of coronary artery disease, possible coronary revascularization, and valvular heart disease. The American College of Cardiology/American Heart Association guidelines for chronic HF has identified this collaborative model as the most preferred one for HF care (7).
A complementary model of training might involve training primary care physicians for one year similar to the one-year clinical geriatric fellowship. Training should involve outpatient and inpatient evaluation and management of HF with additional exposure to echocardiography and nuclear cardiology. During my research fellowship in geriatric medicine, I received clinical training in HF at the University of Alabama (UAB) Advanced HF Clinic. Subsequently, in collaboration with cardiology, I developed two Geriatric HF Clinics at UAB and the Veterans Affairs Medical Center, which provide comprehensive care to older adults with HF. Organizations dedicated in advancing HF training and treatment should promote parallel programs to train general HF specialists alongside cardiology HF specialists. The former group is likely to have the greatest impact on improving the overall quality of care and life of the vast majority of our HF patients.
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1. Adamson PB, Abraham WT, Love C, Reynolds D. The evolving challenge of chronic heart failure managementa call for a new curriculum for training heart failure specialists. J Am Coll Cardiol 2004;44:1354-1357.[Abstract/Free Full Text]
2. Konstam MA, Executive Council of the Heart Failure Society of America Heart failure traininga call for an integrative, patient-focused approach to an emerging cardiology subspecialty. J Am Coll Cardiol 2004;44:1361-1362.[Abstract/Free Full Text]
3. Ahmed A, Allman RM, Kiefe CI, et al. Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care Am Heart J 2003;145:1086-1093.[CrossRef][Web of Science][Medline]
4. American Heart Association Heart Disease and stroke Statistics—2004 updateDallas, TX: American Heart Association; 2004.
5. Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The generalist role of specialty physiciansis there a hidden system of primary care?. JAMA 1998;279:1364-1370.[Abstract/Free Full Text]
6. IPRO Heart Failure. 7th Scope of Work Comparison of Centers for Medicare and Medicaid Services and Joint Commission on Accreditation of Healthcare Organizations Performance Measures. 2004Available at: http://providers.ipro.org/shared/chf/chf_jcaho_charts.doc Accessed October 19.
7. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure) J Am Coll Cardiol 2001;38:2101-2113.[Free Full Text]
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