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Enhancing HF Outcomes: Primary Care
Enhancing HF Outcomes: Primary Care and Cardiology Collaboration

Released: December 04, 2023

Expiration: December 04, 2024

Ty J. Gluckman
Ty J. Gluckman, MD, MHA
Jay H. Shubrook
Jay H. Shubrook, DO, FACOFP, FAAFP
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Key Takeaways
  • With the incidence of heart failure increasing, it is necessary for primary care providers and cardiologists to work together to improve patient outcomes.
  • Prevention of heart failure is key with early management of comorbidities such as hypertension and diabetes, as 24% of individuals older than 20 years of age carry a lifetime risk of developing heart failure.

Heart failure (HF) is a debilitating disease that affects more than 6 million individuals in the United States, and those older than 20 years of age carry a 24% lifetime risk of HF. The role of primary care clinicians in helping to treat HF is expanding, and it is imperative that cardiologists and PCPs work together to improve outcomes for this patient population.

From a primary care perspective, when should we consider screening for HF? 

Jay H. Shubrook, DO, FACOFP, FAAFP:
It is not within our normal workflow to screen for HF as PCPs. I think we need to stop and consider whether we are missing HF. If we are missing the diagnosis, how should we be screening for it? Sadly, from the primary care perspective, HF awareness typically comes after a hospitalization that has led to a diagnosis. At that point, care has historically been almost entirely handed off to the cardiologist. We in primary care have a lot of touch points with our patients and that affords opportunities to optimize management. I think we need to raise awareness of early clinical symptoms of HF, and we need to recognize people who are at risk based on other cardiovascular or metabolic conditions. We also need to improve open communication with our cardiology counterparts about our role vs theirs and be able to identify when we have a shared responsibility.

Ty Gluckman, MD, MHA, FACC, FAHA, FASPC:
I completely agree. There are different stages of HF, and most often, we talk about what is referred to as stage C HF. These are individuals who currently have HF symptoms, such as shortness of breath and swelling of the legs, or have had them in the past while hospitalized or in the outpatient setting. There is also so‑called stage A and B HF that has been called out in recent and previous iterations of the guidelines. Individuals in stage A have risk factors for HF (e.g., hypertension, diabetes, obesity), but have not developed structural abnormalities of their heart (e.g., left atrial enlargement, left ventricular hypertrophy) and are, by definition, asymptomatic. Stage B HF includes those with risk factors and structural abnormalities of the heart, but these individuals have never developed symptoms. For these two groups (stage A and B HF), prevention is key. It is less about screening and more about recognizing the importance of treating these risk factors—hypertension, obesity, sleep-disordered breathing, diabetes, etc. By far, the most prevalent of these is high blood pressure. And data strongly suggests that improved blood pressure control can meaningfully help to mitigate the risk of developing HF. 

How do you think both primary care and cardiology can best support each other when you have a new diagnosis of HF? 

Ty Gluckman, MD, MHA, FACC, FAHA, FASPC:
I continue to be tremendously impressed by my primary care colleagues today with the wide-ranging conditions that they are asked to help manage. Honestly, I don’t know how they do it. HF is just one of these, but one that benefits significantly from team-based care. In short, we work best for the patient when we work together. As such, I think open communication among all members of the care team is critically important; beyond PCPs and cardiology team members, this includes pharmacists, advanced practice professionals, endocrinologists, nephrologists, and others that may be involved in the care of these patients. Addressing wide-ranging comorbidities that affect HF will help improve outcomes, so it truly takes a well-functioning team.

In addition, we are recognizing more and more that certain medications may have a variety of benefits in this population. For example, SGLT-2 inhibitors were initially developed to improve glycemic control, but they are now a class I recommended therapy in HF with reduced or preserved ejection fraction. However, if I initiate an SGLT2 inhibitor in a patient with HF and diabetes, what adjustment of their therapies for glycemic control may be needed? So, again, regular open communication is key.

Jay H. Shubrook, DO, FACOFP, FAAFP:
I love the idea of team-based care. Often, particularly in primary care, we try to go it alone, which is more difficult, and it does not serve the patient best, so using a team-based approach is important. I would also challenge the PCPs to say, “We want bidirectional communication.” That starts with primary care sending a note to the other specialist saying, “This is what I need help with.” If you are doing that, you are much more likely to get a thoughtful and detailed response because it is clear what the request was in consultation. I also think it is worthwhile to ask, “What do you want me and my team to do, and what do you plan to do?” I think the default would be to say, “I’ll just take care of all of it” if I do not have the communication, but in the end, but in the end this does more harm than good in terms of continuity. There is also occasionally the assumption that there would be a plan laid out, and the PCP who has more touchpoints might be taking some of those steps. Without adequate communication, the primary care team member might not see that plan, leading to gaps in care. Ultimately, it all comes down to communication, and I think it needs to start from primary care and progress to other specialists.

Ty Gluckman, MD, MHA, FACC, FAHA, FASPC:
I will add that there are times when both of us could benefit from help—cardiology and primary care alike. For example, in those with worsening kidney function or failure to respond to or tolerate HF medications, co-management with other experts (e.g., nephrologists) may be needed.  These are just a few of the factors that would prompt someone to say, “I need help.” Even within cardiology, advanced HF is now its own board-certified specialty. When I need help, I reach out to a colleague and say, “I have exhausted my capacity to best manage this patient. I need additional assistance.” Increasingly, we should be operationalizing tools to better risk stratify these patients to recognize those that “may be sicker than I otherwise appreciate”. 

What else do you consider when diagnosing and treating HF in a clinic setting? 

Ty Gluckman, MD, MHA, FACC, FAHA, FASPC:
HF is a complex condition that is challenging for all of us. Diagnosing HF among the myriad conditions that can manifest as shortness of breath or edema can be hard. I wish there was a single biomarker or imaging test that could definitively establish the diagnosis of HF 100% of the time. Unfortunately, this is not the case. This is particularly important, as the prevalence of HF is increasing and the fact that its prognosis can rival or exceed that seen with common malignancies. For these reasons, we need to be on the lookout for HF and initiate appropriate risk-reducing treatments wherever possible.

Jay H. Shubrook, DO, FACOFP, FAAFP:
I would say HF is more common than you think, especially in patients with significant comorbidities such as hypertension and diabetes. Physicians should be aware of the earlier risk factors and consider thinking about lumping all these things together. When doing cardiometabolic management, you are also trying to prevent HF as much as possible. And, once you start to have multiple conditions, do not go with it alone. Develop your team, just like patients develop their teams, and ensure the communication is excellent to allow patients to get the best care possible.  

Your Thoughts?
When treating a patient with HF, do you follow a multidisciplinary approach? Join the conversation by leaving a comment below.

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When treating a patient with HF, how often do you use a multidisciplinary approach?

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