Heart Failure Treatment Outcomes and Contraindications

The prevalence of heart failure (HF) is on the climb, with estimates showing up to 8.5 million Americans aged ≥20 years old will likely have the condition by 2030.¹ The state of care prioritizes delaying the progression of HF enough to prolong the need for invasive treatment including left ventricular assisted devices (LVAD) or heart transplant, and to ensure quality and quantity of life is not greatly compromised by the condition.

The first step toward optimizing that care strategy, therefore, would be acceptance—acceptance that HF will present in every frontline clinician’s office regularly, and that there are proven methods to initiate care upon diagnosis.

In the second segment of an interview with HCPLive during the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week,² Ashley Malliett, DMSc, MPAS, PA-C, assistant professor and clinical coordinator at the Michigan State University PA Medicine Program, discussed how adequate HF screening and referral literally implicates the lives of some patients.

“We didn't have the technology that existed about 10 years ago to do this,” Malliett said. “But now technology has gotten so advanced; we have pumps that we can implant and people, keep them alive, get them to a heart transplant and really change the way they live. And the other reality with heart failure, particularly advanced heart failure, is if you catch it early, we can manage it with non-intervention type treatments first. We can use the medications, and then when the medications fail, that's when we can go to more of the diagnostics and therapeutics, in terms of the interventions we have to offer.”

Malliett said she likens LVAD and other device interventions to starting a clock: “those things have an expiration date.” As long as clinicians work to diagnose early and initiate proven treatments, that clock won’t have to start for some time in most patients.

Further delving into LVADs and other assisted devices, Malliett described a number of contraindications associated with them. Cases of bi-ventricular HF, she explained, render LVADs useless. Additionally, major chronic diseases in other major organs, like COPD or kidney dysfunction, can compromise the utility of LVAD.

“If I have somebody on dialysis—these pumps are fluid-dependent,” she explained. “They have one job in the world: pump blood. And with big fluid shifts, you can actually have a lot of hemodynamic instability. So, patients that are on end-stage renal disease, for example, it would be a contraindication.”

More obviously, pregnancy is also a key contraindication for LVAD to treat HF. But lesser known to her patients and peers: cancer in the last 5 years may be a contraindication, due to the use of immunosuppressive therapy post-transplant.

“We have to trick the immune system into thinking that heart is yours,” Malliett said. “And so when we do that, we use immunosuppression drugs, and those drugs increase somebody's risk of cancer by up to 25%, with skin cancer being the most common that we see, followed by some of our hematologic cancers, as well.”

What Malliett advises her peers do is keep honesty at the front of conversation with all HF patients undergoing treatment—especially those considering an escalation to transplant or LVAD.

“If I could tell a patient anything, it's that this isn't a cure,” she said. “You're going to trade one set of problems for another, but it all comes down to your quality of life and what's your definition of quality of life.”

References

1. ^{Bozkurt B, Ahmad T, Alexander KM, et al. Heart Failure Epidemiology and Outcomes Statistics: A Report of the Heart Failure Society of America. J Card Fail. 2023;29(10):1412-1451. doi:10.1016/j.cardfail.2023.07.006}
2. ^{Kunzmann K. Patient Involvement in Advanced HF Treatment, with Ashley Malliett, DMSc, MPAS, PA-C. HCPLive. Published May 21, 2024. https://www.hcplive.com/view/patient-involvement-advanced-hf-treatment-ashley-malliett}