Who Should Deliver Medical Therapy for Patients With Chronic Heart Failure? An Immediate Call for Action to Implement a Community-Based Collaborative Solution.

Abstract

Ever wonder who cares for the 5.7 million patients in the United States with heart failure? Most are initially assessed by a family physician or internist, who after making the diagnosis, often refers them to a cardiologist—not for the treatment of heart failure—but for the evaluation of possible coronary artery disease. When the diagnostic and therapeutic issues regarding a patient’s coronary anatomy have been clarified and after all procedural opportunities have been exhausted, the patient is dutifully returned to the family physician, with a recommendation that he/she implement guideline-directed medical therapy. It is a generalist who cares for most patients with chronic heart failure.1 When we communicate with our colleagues in primary care medicine, why do we convey only a broad philosophical directive rather than a detailed list of specific actionable recommendations? The management of chronic heart failure is not simple. Optimal treatment requires the skillful orchestration of as many as 7 different classes of drugs, together with the appropriate application of different types of devices.2 Heart failure is generally more disabling and lethal than cancer,3 and its comprehensive management is frequently far more challenging. When chemotherapy is given to patients with cancer, its administration is tightly controlled by medical oncologists, who prescribe antineoplastic drugs aggressively and under close supervision, generally at doses and durations that closely resemble those used in randomized clinical trials. Serious adverse effects are expected, but patient compliance and provider enthusiasm is enhanced by societally reinforced fears about the need for aggressive therapy to prevent the silent spread of malignant cells. …