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Cases of heart failure of all varieties are on the increase in the United States and globally, driven by an aging population living longer with comorbidities and conditions whose end results can lead to various forms of heart failure (HF). Common health conditions such obesity, diabetes and kidney disease among others significantly increase the long-term risk of developing heart failure. Cardiovascular conditions, such as atrial fibrillation, hypertension, and coronary artery disease are other common contributing factors in developing heart failure. Individuals diagnosed with reduced ejection fraction (HFrEF) have a five-year survival rate of only 25% after a hospitalization.
In July, the UPMC Heart and Vascular Institute (HVI) opened a new multidisciplinary clinic for patients with heart failure with reduced ejection fraction who have had a de novo or updated cardiac resynchronization therapy (CRT) device implanted to better control their HF. Discussions and planning for the new clinic began in the Fall of 2019.
Advanced heart failure specialist Brittany Palmer, MD, collaborated with Mary Keebler, MD, medical director of the UPMC HVI Heart Failure Center, and electrophysiologist Sandeep Jain, MD, director of Cardiac Electrophysiology at UPMC, to develop and launch the clinic.
The clinic's focus is to improve and optimize care for all patients who have had a CRT device implanted in procedures conducted at UPMC Presbyterian. However, the new clinic is particularly interested in identifying individuals who are poor or nonresponders to their therapeutic intervention and thus have a worse prognosis with an increased risk of mortality and morbidity.
“Approximately one-third of patients who have a CRT device implanted to manage their heart failure do not respond or have suboptimal responses. It is these patients who may benefit the most from the focused, multidisciplinary assessment and management of the collaborative group of advanced heart failure specialists and cardiac electrophysiologists at the new UPMC HVI CRT-HF Clinic,” says Dr. Palmer.
Heart failure patients who are nonresponders to CRT may benefit or improve thorough medication adjustments, CRT device setting changes, and cardiac rehabilitation. Patients who are nonresponders also can be evaluated for advanced therapies to treat their heart failure, such as ventricular assist devices (VADs) or to determine if they are candidates for cardiac transplantation or other interventions.
“Morbidity, impairment of quality of life, and mortality can be very high with this HF patient population, even with all the new treatment options and evidence-based therapies we have at our disposal. Hospitalizations are common and costly and can greatly impact a patient’s functional capacity and well-being. Understanding the individual patient and developing the best options for care requires a collaborative and multidisciplinary approach. That is how we have structured the new clinic,” says Dr. Palmer
Patients are seen in UPMC Mercy HVI Clinic in a one-time visit by a team consisting of the implanting electrophysiologist along with Dr. Palmer and her heart failure team. These visits are scheduled to occur six months post-device implantation for both new and upgraded devices.
“We originally planned for our patient visits to occur three months’ post-implantation, but we found that a six-month interval between implantation and follow-up at the CRT-HF Clinic affords us a much better understanding of the patient’s condition and their response to therapy,” says Dr. Palmer.
Clinic visits follow a defined structure. Every patient is subjected to the same battery of tests and follow-up assessments to gauge their status and need for changes to their device settings and medication regimens.
All patients have an echocardiogram, and each individual performs a 6-minute walk test to assess functional capacity, heart rate, and O2 levels.
“Our electrophysiology (EP) device nurses perform a device interrogation using a standardized checklist that we collaboratively developed and that includes a number of red-flag indicators that will prompt a recommendation for an individualized and in-person visit with the patient's implanting electrophysiologist to further assess the patient's device settings and possibly make additional adjustments," says Dr. Palmer.
From that point, patients meet with Dr. Palmer for a thorough review of their heart failure history, prior cardiac testing, functional capacity, medications, and to undergo a physical exam. Based on this work-up, recommendations are made which can include medication changes or titration, cardiac rehabilitation, and occasionally assessment for more advanced therapies.
Dr. Palmer and her team evaluate the patient for signs of frailty that could impact their overall health and heart function. Those patients who meet the criteria are prescribed cardiac rehabilitation protocols.
Future changes or enhancements to the clinic are already being discussed and planned. These include a more rigorous frailty testing protocol that includes both a handgrip test and a "get up and go" test to check for frailty or signs of physical decline.
“Another addition to the clinic protocol that is under discussion for implementation in the future is a cognitive evaluation. Heart failure patients tend to have multiple risk factors for cognitive decline which can contribute to difficulty managing medication regimens and appointments, adhering to dietary modifications, and performance of activities of daily living. Identification of such issues is the first step in figuring out how to intervene,” says Dr. Palmer.
Partnership and collaboration with a patient’s existing cardiologist are central to the mission of the CRT-HF Clinic.
“Our goal is to work with the patients’ primary cardiologist to offer this at-risk population a more comprehensive level of care that can keep them out of the hospital and as healthy and functional as possible,” says Dr. Palmer.
The results from the patient’s assessment and recommendations for the patient’s cardiac care are communicated with each patient’s primary cardiologist with whom the patient continues to follow.
While notes and communications through the electronic medical health record are forwarded to providers as part of the routine care follow-up, one of the CRT-HF clinic goals is a more personal and in-depth level of communication.
“We routinely use direct phone calls and emails to the treating cardiologist to relay our findings on the patient’s health and status, and to discuss our recommendations for treatment changes and adjustments. We believe having more direct communication leads to better patient care and trust between providers,” says Dr. Palmer.
Patient Referrals and Questions
To learn more about the CRT-HF Clinic at the UPMC Heart and Vascular Institute, or to discuss a patient for referral, please contact 1-844-UPMC-HEART (876-2432).
1. Shah KS, Xu H, Matsouaka RA, et al. Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction: 5-Year Outcomes. J Am Coll Cardiol. 2017; 70(20): 2476-2486