James Mudd, M.D.
Dr. Mudd is the medical director of the Heart Failure and Transplant program at the OHSU Knight Cardiovascular Institute. His research interests include right heart failure, ventricular assist devices, symptom management in chronic heart failure.
OHSU Knight Cardiovascular Institute
Caring for patients with heart failure
Heart failure (HF) is one of the most serious conditions primary care providers treat, and Americans over the age of 40 with high blood pressure have a 20 percent lifetime risk. The heart failure team at OHSU Knight Cardiovascular Institute, which recently earned Joint Commission Advanced Certification in Heart Failure, offers suggestions to reduce morbidity, improve quality of life, and potentially slow disease progression.
Current heart failure therapies
Just as patients with a new cancer diagnosis see an oncologist, those with a new HF diagnosis should see a cardiologist for a comprehensive evaluation. Ensuring appropriate medical therapy is key starting point. In general, patients with heart failure benefit from ACE inhibitors or angiotensin receptor blockers and beta blockers. Spironolactone is often underutilized because of renal insufficiency or high potassium, but should not be overlooked given the mortality benefits. If renal function worsens, it may seem appropriate to stop the ACE inhibitor or ARB, but patients with heart failure should take a vasodilator and substituting hydralazine and nitrates for afterload reduction is important.
HF in specific patient populations
Women with cardiovascular disease may present with different symptoms than men, so heart failure may be unrecognized.
Specific therapies, such as hydralazine and nitrates, are specifically indicated for African-American patients in addition to other more standard medications. This finding is based on a large Veterans Affairs study that included study of a sub-population of African-American patients.
Cardiology-primary care teams
In our practice, we work closely with internists and family practice providers at OHSU and elsewhere and with cardiologists from around the Pacific Northwest. For example, we may see a relatively stable patient in the HF clinic every six months. If the patient sees the primary provider between cardiology visits, he or she is checked every three to four months. Sharing care between cardiology and primary care ensures patients with this condition are closely monitored.
Ventricular assist device and transplant for advanced HF
Heart failure is a progressive condition, and at some point, the disease and symptoms progress despite medications. Some patients are candidates for a ventricular assist device (VAD). This surgically implanted heart pump supports patients awaiting transplant or non-transplant candidates. Currently, our team cares for more than 70 such patients around Oregon. Heart transplant is another option for appropriate patients, and OHSU is home to Oregon’s only heart transplant program.
Markers of worsening HF
Knowing the signs of disease progression is crucial to managing patients with HF effectively. These signs include:
- Sentinel events, such as emergency department visits, hospitalizations and rehospitalizations
- Escalating diuretic dosage
- Low blood pressure
- Inability to tolerate some medications, e.g., lower ACE inhibitor dose due to declining renal function
- Shocks from an implanted cardioverter-defibrillator
- Low serum sodium
- Persistently high B-type natriuretic peptide despite escalating or maximum medication dose
Two ED visits or hospitalizations in six months should prompt a visit to the cardiologist or referral to a comprehensive heart failure clinic. The American College of Cardiology Foundation and American Heart Association released new heart failure management guidelines in 2013, published in Circulation. The OHSU heart failure team is always available to consult on these guidelines.
Managing HF proactively
Patients with heart failure have a predictably unpredictable condition, but a systems approach can decrease the number of emergency calls and visits as well as morbidity. Patients with heart failure may need a provider at a moment’s notice, when neither the primary provider nor cardiologist has capacity, making it essential to manage urgent and chronic concerns proactively. For example, our clinic’s heart failure nurse can triage patients to the clinic, ED, or laboratory and provide continuity, support and education to patients and families. In addition to our heart failure nurse, the OHSU heart failure team has a nurse or heart failure cardiologist on call 24-7.
Patient education and yearly care goals
Some patients live very well with heart failure, but its progressive nature cannot be ignored. The table below recommends patient education on specific topics. A cardiology partner can assist in talking about potentially difficult issues. OHSU offers Heart Failure University to educate hospitalized patients and families.
|Heart failure topics for patients and families|
|Primary provider or cardiac specialist|
Weight and dietary restrictions
Activity level – Cardiac rehabilitation is now covered for patients with ejection fraction < 35%, and exercise can improve quality of life
Progressive nature of HF – At least annually, discuss care goals
Defibrillator or biventricular pacemaker ICD for patients with depressed ejection fraction
Genetic counseling and testing – For patients with familial HF
The Joint Commission Awards
OHSU’s Heart Failure Team
In February 2015, OHSU’s heart failure team received The Joint Commission’s Gold Seal of Approval, the first and only Pacific Northwest hospital to earn this distinction. The program also received the American Heart Association’s Heart Check-Mark for Advanced Certification in Heart Failure.
Your partner in managing and treating HF
The OHSU Heart Failure Program is your partner in managing HF from any cause. We are the only heart transplant center in Oregon and the Pacific Northwest’s only heart failure program with Joint Commission Advanced Certification in Heart Failure.
We are always available to consult or assist you in helping your patients. To refer a patient or consult with our team, call the OHSU Physician Consult & Referral Service at 800 245-6478.Back to articles