Highlights
- •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.
ABSTRACT
Background
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.
Methods
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.
Results
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.
Conclusions
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.
Key Words
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Article info
Publication history
Published online: June 15, 2021
Accepted:
May 19,
2021
Received in revised form:
May 19,
2021
Received:
September 11,
2020
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
