People With Heart Failure Hospitalized Less Often When Specialists Treat Them, Study Finds

November 03, 1997

DALLAS, Nov. 4 -- People with heart failure fared far better in the care of cardiologists and trained specialists than in the hands of internists and family physicians with limited expertise in treating the condition, a new study published today in the American Heart Association journal Circulation shows.

Heart failure is a condition in which the heart can't pump enough blood to meet the demands of the body, leading to shortness of breath and fluid retention.

One reason for the improved results from specialists may be "more aggressive" therapy with diuretics -- medicines that purge the excess fluid from tissues. Those treated by specialists received higher doses of diuretics, which were shown to cut in half the rate of hospitalizations for heart problems. In addition, people treated aggressively were able to undergo exercise testing without becoming exhausted, says Sai Hanumanthu, M.D., and co-investigators at Vanderbilt University Medical Center in Nashville, Tenn.

One-year survival for the entire group of patients treated by specialists was 87 percent -- "substantially better," the researchers say, than the outcome for any other group of patients with moderate-to-severe heart failure.

"Our findings suggest that individuals with heart failure had fewer hospitalizations and fewer symptoms, such as shortness of breath, when their care was transferred from generalists to cardiologists and a support staff who specialize in the management of such patients," he says.

During the year before referral to specialists, 94 percent of the patients in the study were hospitalized; 44 percent of the patients were hospitalized during the year after referral -- a 53 percent reduction. And 88 of the individuals who were able to exercise on a treadmill at the time of referral significantly increased their exerise ability during follow-up, says Hanumanthu.

Upon referral to specialists, most of the individuals already were receiving highly effective -- but not universally prescribed -- drugs for heart failure. A surprising 76 percent were getting drugs called ACE inhibitors and 88 percent were receiving digoxin -- substantially above national averages, according to other studies. And while nearly all were getting some form of diuretic, special-care physicians considered the dosages inadequate for optimal treatment.

Within six months, average daily doses of loop diuretics were doubled, from 94 to 181 milligrams, the researchers report.

"Individuals with complicated chronic disease syndromes such as heart failure should be managed by specialists or in specialty clinics devoted to such patients," William T. Abraham, M.D., and Michael R. Bristow, M.D., of the University of Colorado say in an editorial accompanying the study. But today, they note, physicians who are not cardiologists care for 83 percent of heart failure patients.

Another factor in the improved health and reduced hospitalizations, the scientists say, was "more appropriate" use of beta-blocker drugs and "anti-arrhythmic" agents -- drugs designed to subdue irregular heartbeats. In some individuals, the occasionally controversial drugs were deemed inappropriate and were discontinued in both groups of patients.

"At present, most patients with heart failure are managed by primary-care physicians and internists with little special expertise in heart failure," Hanumanthu and his colleagues pointed out. "It is becoming clear that this system results in excessive costs and relatively poor outcomes."

Researchers looked at rates of hospitalization, drugs and peak exercise capacity at 134 patients referred to Vanderbilt's specialized heart failure and transplant program between July 1994 and June 1995. The study included 39 women and 95 men, average age 52 years.

During a time when the death rates from heart attacks and strokes declined, chronic heart failure has increased dramatically in the United States -- from 250,000 people diagnosed in 1970 to nearly 700,000 in 1992, according to Abraham and Bristow. Congestive heart failure afflicts almost 5 million Americans, or about 1.5 percent of the nation's population, they estimated.

"Specialized heart-failure centers offer complex, cost-effective treatments not available in other settings," according to Abraham and Bristow. These treatments include heart transplantation and other high-risk heart surgeries, and experimental medical treatments not yet approved by the Food and Drug Administration.

An example is carvedilol, a "third-generation" beta-blocker drug shown to be effective in treating heart failure. Before FDA approved it, carvedilol was available only in specialty heart- failure centers, the two experts say.

Monitoring of optimal drug levels was just part of intensive management program. Everyone in the study received extensive testing of the heart's main pumping chamber, the left ventricle. Heart function was monitored regularly by three physicians who work exclusively with heart failure and heart transplant patients, assisted by cardiovascular nurse specialists. All of the strategies employed are "standard practice" in specialized centers, the researchers said.

Other co-authors of the study are Javed Butler, M.D.; Don Chomsky, M.D., and Stacy Davis, M.D. John R. Wilson, M.D. directed the study.

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American Heart Association

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