Cardiologist, Primary-Care Management Differs in Preserved-EF Heart Failure

October 01, 2018

NASHVILLE, Tennessee — A lot of primary-care physicians manage patients with heart failure and preserved ejection fraction (HFpEF), but not necessarily the way a cardiologist would and often without knowing the relevant guidelines, suggests a small survey of physicians.

The 82% of 245 respondents who were not cardiologists, compared with 18% who were, also reported greater reliance on diastolic dysfunction by echocardiography to make a HFpEF diagnosis and tended to manage HFpEF more like heart failure with reduced ejection fraction (HFrEF).

"We defined two groups that care for the same population potentially differently," David Saxon, MD, University of Michigan, Ann Arbor, told | Medscape Cardiology.

"We're not necessarily pointing the finger at anybody, but just showing that there are differences in how the processes of care are occurring and probably opportunities to improve that."

About 93% of the responding noncardiologists and more than 98% of the cardiologists said they routinely care for patients with HFpEF, he said, but the survey didn't ask whether they actually manage their heart failure.

Noncardiologists at the two major university-affiliated health systems where the survey was conducted consisted of family practitioners, general internists, and geriatric medicine specialists, Saxon said. He presented the findings here at the Heart Failure Society of America 2018 Meeting.

One of the key insights, he said, is that many noncardiologists "are managing HFpEF on their own, without referring." Only about 37% of them reported referring such patients to a cardiologist, whereas the referral rate for HFrEF was about 63%.

The most commonly cited reasons for noncardiologist referral to a cardiologist, Saxon said, were a presence of concomitant pulmonary hypertension or right-ventricular dysfunction, or a history of multiple hospitalizations.

More than twice the proportion of cardiologists as noncardiologists reported being aware of either the European or North American guidelines for managing HFpEF. Still, only 65% of responding cardiologists reported such awareness, a proportion Saxon called "pretty staggering."

The survey didn't distinguish between general cardiologists and those with subspecialties like catheter interventions, electrophysiology, or heart failure and transplant medicine.

Differences showed up as well in how HFpEF patients were medically managed. For example, fewer noncardiologists were likely to give them aldosterone antagonists.

Cardiologists reported using aldosterone antagonists for HFpEF more often than beta blockers or ACE inhibitors or angiotensin receptor blockers (ARBs), suggesting —perhaps — that many of them are aware of the TOPCAT trial's post hoc finding of possible benefit from spironolactone in such patients.

Agreement With Survey Questions About HFpEF by Noncardiologists and Cardiologists
Issues Regarding HFpEF Noncardiologists (%) Cardiologists (%) P Value
Aware of ACC/AHA or ESC diagnostic guidelines 26 65 <.001
Rule out if no diastolic dysfunction on TTE 41 6 <.001
Diagnose in all with diastolic dysfunction on TTE 35 3 <.001
Use low natriuretic peptide levels to exclude diagnosis 34 27 NS
Prescribe exercise program in at least half of cases 47 43 NS
Prescribe ACE-I/ARB in at least half of cases 58 44 NS
Prescribe beta blockers in at least half of cases 55 56 NS
Prescribe aldosterone antagonists in at least half of cases 31 65 <.001
ACC=American College of Cardiology; AHA=American Heart Association; ESC=European Society of Cardiology; TTE=transthoracic echocardiography

Saxon further noted that despite significant morbidity and mortality associated with HFpEF, "noncardiologists seem to put lower emphasis on discussing prognosis and treatment goals in patients with HFpEF," compared with cardiologists.

About 70% and 85%, respectively (P < .001) said they discuss heart failure prognosis or goals of care with such patients.

"But what I find the most interesting is that exercise programs are underutilized," Saxon said. Despite abundant evidence for improvement in functional capacity in HFpEF with increasing exercise levels, fewer than half of respondents in both groups said they prescribe an exercise program for such patients.

The survey was sent to 1010 physicians belonging to health systems associated with the University of Michigan Medical Center and Weill Cornell Medicine/New York Presbyterian Hospital, of whom 245 completed "a significant proportion" of the form and returned it anonymously.

Saxon had no disclosures.

Heart Failure Society of America (HFSA) 22nd Annual Scientific Meeting: Abstract 126. Presented September 15, 2018.

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