Who is managing acute decompensated heart failure? The need for a multidisciplinary approach

Abstract

A cute decompensated heart failure (ADHF) is a common disorder that is frequently managed by hospitalists. This management is expected to expand over the next several years because of a continuing increase in the number of ADHF admissions coupled with a plateau or possible decline in the number of practicing cardiologists (Figure 1). [1][2][3][4][5][6][7][8][9][10][11][12][13][14] In addition, 12% of fellowship training positions in cardiology were eliminated between 1995 and 2001, and the fact that the current number of training positions is inadequate to meet future demands is not recognized. 15,16 Given the severity of this disorder, the limited data from randomized, controlled clinical trials, 17 and the limitations of current treatment, this management can be both challenging and rewarding. The goal of this special supplement of the Journal of Hospital Medicine is to assist hospitalists in this endeavor by summarizing the currently available data and treatment options and presenting a rational evidence-based algorithm for the management of ADHF.A multidisciplinary approach to heart failure has been shown to reduce cost, decrease length of stay, curtail readmissions, and improve compliance.18-20 By leading and coordinating teams of physicians, pharmacists, nurses, nutritionists, physical therapists, and case managers and by developing and implementing indications for cardiology consultation, hospitalists can facilitate this multidisciplinary approach. 21,22 However, it is important to remember that hospitalists do not replace cardiologists, who remain a valuable and key component of this multidisciplinary team. Their input is vital in developing care pathways and criteria for consultation, and they, along with primary care physicians, will be the primary source of patient care following hospital discharge. Good communication between hospitalists and cardiologists is essential to optimize the care of patients with ADHF.Maximizing the efficacy of ADHF care requires a thorough understanding of (1) the causes and potential treatments for the patient's acute decompensation, (2) the management of the patient's chronic heart failure, and (3) potential future therapies. Strategies to improve the continuum of heart failure care have been employed to help improve patient outcomes.23 For example, hospital-based disease management programs have consistently been shown to optimize care and reduce rehospitalization rates in patients with heart failure. 24 These programs involve a multidisciplinary, multifaceted approach to care in order to provide a continuum of care extending from hospitalization and into a patient's home environment.Alpesh Amin received research support and editorial assistance from OptumHealth Education through an educational grant from Otsuka American Pharmaceuticals and an honorarium from OptumHealth Education, in support of this work.

The role of the emergency department in acute heart failure clinical trials—Enriching patient identification and enrollment

“…Because most patients don't require intensive care and respond to “routine” therapy, many are admitted to hospitalists and other non-cardiology services. 10 Those patients who have complicated presentations such as hypotension, cardiorenal syndrome or coronary ischemia, are more likely to be admitted to a cardiologist. The initial presentation, along with complicating comorbidities, high post-discharge event rates, and a lack of easy risk-stratification tools, have resulted in the current practice of most emergency physicians: inpatient admission.…”