Connections: When is the optimal time for intervention in advanced heart failure? | Spring 2021

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From OHSU Knight Cardiovascular Institute

Conrad Macon, M.D.

Conrad Macon, M.D.

Dr. Macon specializes in advanced heart failure and heart transplant. He is part of the advanced heart failure team. In his research, Dr. Macon is focusing on modern gene editing methods to make a possible “universal donor” for organ transplantation.

Timing of intervention for advanced heart failure therapies represents the million dollar question that all advanced heart failure specialists strive to address: When is a patient sick enough to benefit from advanced therapies but not so sick that they will have poor outcomes?

At the OHSU Advanced Heart Failure Program, our team evaluates and individualizes heart failure treatments to maximize outcomes for patients, while respecting individual preferences. The goal for all advanced heart failure therapies is to improve both quality of life and quantity of life for each patient.

Heart failure deserves the same urgency in initiating treatment as cancer diagnosis

Evaluation and treatment of heart failure is very time sensitive, with delays leading to substantial increases in morbidity and mortality.

In many ways, a diagnosis of heart failure is similar to a diagnosis of cancer. If caught early, and treated with appropriate medical therapy, we can dramatically improve the trajectory of the disease.

Although our Advanced Heart Failure Program is very good at stabilizing patients with advanced stage D heart failure, often the intervention options become limited due to disease progression and other organ dysfunction.

The clock starts counting down when a patient’s cardiomyopathy progresses to advanced stage D heart failure.

This population of patients has a survival rate of 25% at one year without definitive advanced heart failure therapies, which include cardiac transplantation or left-ventricular assist devices (LVADs). A diagnosis of advanced heart failure confers a worse prognosis than pancreatic cancer.

However, with definitive therapy, the survival rate increases to greater than 80% at one year with an LVAD and a median survival of 10–12 years with cardiac transplantation.

Stratifying early stage C patients for further evaluation

One challenge in identifying this patient population is that it can be easy to underestimate the severity of a patient’s heart failure. The progression of symptoms is often insidious, and patients find ways of coping with worsened symptoms.

Studies show that even advanced heart failure cardiologists are only able to identify patients with low cardiac output 50% of the time when based on history and physical exam. Ideally, we would like to identify patients before decreased perfusion endangers other organs.

One noninvasive way to evaluate this is with a specialized cardiopulmonary exercise stress test. This test provides clear indicators about a patient’s functionality and prognosis. It is also an excellent tool for differentiating dyspnea due to other causes, such as pulmonary disease or deconditioning. Our Cardiopulmonary Exercise Testing lab here at OHSU is adept at performing and interpreting this test.

When to refer

Other indicators that are often overlooked and should trigger an evaluation by an advanced heart failure cardiologist include:

  • Frequent hospitalizations
  • Worsening renal function
  • Inability to tolerate heart failure medications due to hypotension
  • Frequent defibrillator shocks
  • Worsening diuretic resistance
  • Poor quality of life due to cardiac dysfunction
  • Progression of frailty in the setting of heart failure

Exceptional transplant care adding multi-organ capability

The OHSU transplant program has been growing rapidly this year, despite the limitations imposed by the COVID-19 pandemic.

In 2021, OHSU is commencing a heart and kidney concurrent transplant program, which will be the only program in the state to offer multi-organ transplant.

Carefully selected patients who receive simultaneous heart-kidney transplant have improved outcomes compared to heart transplant alone.

Offering this service to OHSU will allow us to provide a greater portion of the population in Oregon a critical life-saving treatment.

OHSU performed Oregon’s first heart transplant in 1985, and more than 700 transplants later, remains the only program in Oregon approved by the United Network for Organ Sharing and the Centers for Medicare & Medicaid Services.

Contact us

The OHSU Knight Cardiovascular Institute provides the full spectrum of care for cardiovascular disease. We are available to answer questions about all treatment options.

Please call the OHSU Physician Advice and Referral Service at 5034944567. To refer a patient, please fax to 5033466854.