Research Article| Volume 27, ISSUE 11, P1251-1259, November 2021

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Practices of Referring Patients to Advanced Heart Failure Centers


      • Most referrals for advanced heart failure (AHF) therapies originate from heart failure (HF) cardiologists.
      • Worsening HF, inotrope dependence, hospitalization, and shock often prompt referral.
      • Many patients are too ill or have psychosocial limitations precluding AHF therapies.
      • Patients referred by HF cardiologists were more likely to receive AHF therapy.



      Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers.


      We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients’ demographics, referring providers’ characteristics, referral circumstances, and evaluation outcomes were collected.


      The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1–3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly, AHF therapies were not offered because patients were too sick (38.0%–45.1%) or for psychosocial reasons (20.3%–28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy, and 14.5% were referred to hospice.


      In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.

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