Managing systolic heart failure

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Primary care providers can help significantly reduce heart failure exacerbations and improve their patients’ overall quality of life.
Primary care providers can help significantly reduce heart failure exacerbations and improve their patients’ overall quality of life.

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The American Heart Association has identified heart failure (HF) as the No. 1 reason why patients are readmitted to an acute-care facility within 30 days.1 Preventing the exacerbation of HF is expected to improve overall quality of life and survival rates, and to decrease significantly the healthcare costs related to acute-care treatments. 

HF is a complex condition that develops from a combination of health and environmental factors; management requires a multidisciplinary approach. Aggressive and appropriate outpatient management may be time-consuming and labor-intensive but can result in improved survival and a better quality of life for patients. On the frontline of this effort are primary care providers, who can contribute significantly to reducing HF exacerbations and improving their patients' overall quality of life. 

Disease burden

In 2013, HF was mentioned as the underlying cause of death in more than 65,000 patients in the United States. It is projected that the prevalence of HF will increase by 46%, affecting more than 8 million people, by the year 2030.2 HF accounts for nearly 1 million emergency room visits and is the No. 1 reason for the readmission of patients on Medicare.1 Projections show that by 2030, the costs to treat HF will increase almost 127%, from $30.7 billion in 2012 to $69.7 billion in 2030.2 

The prevalence and incidence of HF are expected to continue to increase, in part because of the aging population and in part because of an increasing need for earlier and more aggressive outpatient management. Patients with HF have multiple comorbidities; therefore, treatment decisions require balancing risks and benefits. Additionally, these patients require more frequent monitoring.

Definitions

Although HF is not clearly defined in the literature, the general consensus is that systolic heart failure (SHF) is an ejection fraction (EF) of 40% or lower and can be identified as heart failure with reduced ejection fraction (HFrEF). Diastolic heart failure (DHF), or heart failure with preserved ejection fraction (HFpEF), is a combination of the signs and symptoms of heart failure, a preserved EF, and evidence of diastolic dysfunction involving both ventricles or only one. 

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The American College of Cardiology (ACC) and the American Heart Association (AHA) have staged heart failure on the basis of symptoms. Because of the complexities of HF, only the management of SHF is discussed in this article. Table 1 describes the ACC/AHA stages of heart failure and provides examples. Table 2 compares stages and class. 

Systolic heart failure is caused by a progressive deterioration of heart function and sometimes can take years before symptoms manifest. Early diagnosis and the aggressive management of known risk factors, such as hypertension, diabetes, obesity, alcohol abuse, and tobacco use, are the best strategy to prevent functional decline. Additionally, patients with a family history of coronary artery disease or idiopathic cardiomyopathies and those with a history of rheumatic fever should be monitored more closely as they age. 

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