Worsening and Hospitalization in Heart Failure

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The MD Magazine Peer Exchange “Managing Heart Failure Today: Current Best Practices and New Treatment Options” features a panel of physician experts discussing key factors to consider when making treatment decisions for patients with heart failure and their own clinical experiences with recently approved medications for the treatment of heart failure.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Michael Felker, MD, MHS, professor of medicine and chief of the Heart Failure Section at Duke University School of Medicine, in Durham, NC
• Milton Packer, MD, Distinguished Scholar in Cardiovascular Science, Baylor Heart and Vascular Hospital, Baylor University Medical Center, in Dallas, TX
• Scott Solomon, MD, Senior Physician and director of Non-Invasive Cardiology at Brigham and Women’s Hospital, and Edward D. Frohlich Distinguished Chair and professor of medicine at Harvard Medical School, in Boston, MA
• John R. Teerlink, MD, director of Heart Failure at San Francisco Veterans Affairs Medical Center and professor of medicine at UCSF in San Francisco, CA

Peter Salgo, MD: You have patients who have heart failure. We’ve already said that a lot of them come to you pretty late. They’ve been at home thinking they’re getting old, when really, all that they’re getting is [heart] failure. When do you bring them into the house? What are the reasons to bring people into the hospital because of heart failure?

Scott Solomon, MD: Well, patients will often tell you when they are starting to decompensate because they’re going to feel a lot worse. They’re going to get more dyspneic—first on exertion, and then ultimately, at rest. They’re going to also have signs of fluid overload. These are the main reasons that we bring patients into the hospital.

Peter Salgo, MD: But don’t all heart failure patients have some signs of fluid overload?

Scott Solomon, MD: There’s probably a difference between a little bit of pedal edema, and overt neck vein elevation, and overt fluid overload—the kind that we would want to bring somebody in for. The problem is that we don’t have very good therapies for acute decompensated heart failure at this point in time.

Peter Salgo, MD: What about chronic decompensated heart failure? That’s what we’ve been talking about, right?

Michael Felker, MD, MHS: I think the key issue is that there are chronic interventions we want to make to try to modify the natural history of the disease, which we’ll talk about some more. But then, along that course, there are these waxing and waning exacerbations.

I think a key trigger to ending up in the hospital is [when] you get in a situation where [there is] adjustment of oral medications, whether it’s diuretics or other things, and [it becomes] insufficient to restore some amount of clinical stability. Those are the people that end up hospitalized.

Peter Salgo, MD: If I hear you right, you bring somebody in the house for, probably, 2 reasons. Once there comes a life-threatening issue that you have to deal with, or [when] simply fiddling with the home medications is not enough. You want to get control over this and reset everything and then send them back out?

Milton Packer, MD: Only because of the fact that, in general, you hospitalize someone because either the seriousness of their clinical presentation is such that they need ongoing observation for whatever reason, or the rapidity of changing their medications is such that they need ongoing observation.

For the vast majority of people who have come in with chronic heart failure, hospitalization isn’t necessary. For the vast majority of people, you need a diagnosis, you need to be aware of the syndrome, and you need to implement therapy—that doesn’t require hospitalization.

Peter Salgo, MD: So you brought somebody in and you put them on a drip. Let’s say dobutamine for the sake of argument—I don’t care what you put them on. Now what are you going to do? Where’s he going to go from there?

Scott Solomon, MD: We don’t do very much of that.

Milton Packer, MD: You wouldn’t do that.

Peter Salgo, MD: I see it all the time. Don’t tell me they don’t do it. I see it every day.

Michael Felker, MD, MHS: I see this as a complicated issue, but there [is only] a small portion of the heart failure population [with] very end-stage disease.

Peter Salgo, MD: I guess I see the sickest of the sickest.

Michael Felker, MD, MHS: Yeah. I think this is a good example. John [John R. Teerlink, MD] mentioned this earlier—the selection bias of working at academic centers, and certainly working in an intensive care unit setting, that we all probably are liable for.

Peter Salgo, MD: So you’re telling me you’re going to bring them in for less drastic interventions, and more adjustments and titrations?

Milton Packer, MD: No, we’re not going to bring them in. The way to think about heart failure is [that this is] a long-term serious disease, which is inherently progressive. The way to make sure that patients get treated is to focus not on what happens in an inpatient setting, but what happens in an outpatient setting. Most of their life will be spent as an outpatient, and most of what determines their life will happen as an outpatient.

Peter Salgo, MD: That is a wishful thought and that’s what we all want, because if they’re spending the rest of their life in a hospital, we’ve done it wrong.

Scott Solomon, MD: Obviously, these patients do come into the hospital from time to time. But to Milton’s [Milton Packer, MD’s] point, we could be doing a much better job at keeping them out of the hospital. There’s enormous incentive right now, even financial incentive, for hospitals to ensure that patients don’t get hospitalized with heart failure.

Peter Salgo, MD: Got it. Then let me ask one last question, and then I’m going to move on. All you hear in the popular press is that everything can be dealt with [through] diet, exercise, and lifestyle. We’re sick because we’re making ourselves sick. Heart failure is part of this. The doctors want to push pills. When is lifestyle modification not enough?

Milton Packer, MD: In someone with heart failure, [lifestyle modification] is a little bit too late. Most of the things that we would advocate for reducing cardiovascular risk, we would do to prevent heart failure. But in someone already with heart failure, we would love to maintain activities of daily living. A lot of physicians mistakenly tell them to go home and rest.

Peter Salgo, MD: Now you’re sounding old.

John R. Teerlink, MD: This paternalistic, “Oh you poor thing. You have heart failure. You need to take it easy and rest your heart.”

Milton Packer, MD: Right. It doesn’t work. Diet is unbelievably controversial these days. We’re not even certain that we know what diet should be given to patients with heart failure. We used to worship a low-salt diet. We’re not exactly certain that that’s entirely appropriate.

Michael Felker, MD, MHS: It’s kind of ironic, because whole practice patterns have been built around this idea of trying to enforce a low-sodium diet in heart failure patients. And now, as Milton [Milton Packer, MD] said, it’s actually quite controversial whether it’s a good thing. And that’s either in the outpatient setting or even those that are hospitalized.

Peter Salgo, MD: Just for the record, you could try to enforce a low-sodium diet all you want, but nobody sticks to it. They just can’t. It’s just awful.

Milton Packer, MD: And reduction of cholesterol by diet, in some with heart failure, [isn’t] a good expenditure. It doesn’t make a lot of sense.

Michael Felker, MD, MHS: But I think it was analogous to cancer. If you have cancer, maintaining a healthy lifestyle is a good thing to do. But it’s insufficient to treat the serious disease that you’ve been diagnosed with.