Treating Heart Failure: The Smartest Approach

Many doctors don't provide the right treatments, triggering unnecessary hospitalizations—even deaths.

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About 5 million people in the United States have heart failure, and 300,000 die from it every year. (Compare that with the 570,000 annual deaths caused by every kind of cancer.) Indeed, heart failure—the heart can't pump enough blood through the body—is the most common reason older folks wind up in the hospital, and more than 1 in 4 heart-failure patients must be hospitalized again within a month of being discharged, according to a recent study in the New England Journal of Medicine. That's despite the fact, the American Heart Association contends, that most of these rehospitalizations are preventable. "We can take the failure out of heart failure if we use all of the available treatment strategies to the best of our abilities," says AHA President Clyde Yancy, chief of cardiothoracic transplantation at Baylor University Medical Center in Dallas.

The problem, he says, is that many hospitals and doctors still aren't following the AHA's evidence-based guidelines for treating heart disease, which have been shown to reduce the rate of rehospitalization or death by more than 20 percent in the first two months after patients leave the hospital. The organization says about 460 hospitals in the United States are currently enrolled in its "get with the guidelines" program, whose website allows doctors to enter information about a heart-failure patient and get a recommended course of treatment that might include a combination of medications, dietary restrictions, and possibly an implantable pacemaker. These participating hospitals, however, account for about 275,000 heart-failure patients—just a fraction of those who are hospitalized for treatment.

Thus, the onus may be on patients to ensure that they're getting the best possible care. Here's what you need to know if heart failure is a possibility:

When to get a diagnostic workup. Uncontrolled high blood pressure can lead to heart failure over time. So, too, can a previous heart attack that leaves the heart muscle permanently damaged. Telltale symptoms include shortness of breath, tiredness, and difficulty with physical exertion. You should get these symptoms checked out by a doctor. If your symptoms are severe enough to warrant hospitalization, the AHA recommends the following workup before you're discharged: a thorough medical history, a physical exam, and blood tests to measure certain proteins, electrolytes, and other markers of heart failure. A chest X-ray may also be useful to check for fluid in the lungs, a common heart-failure complication. You might also need an echocardiogram or some other heart imaging test, says Yancy. This will reveal if the inability to push out sufficient blood (called low ejection fraction) is because the heart has become flabby and enlarged or because the muscular walls have stiffened. It will also reveal whether the different parts of the heart that squeeze and relax in sequence have lost their perfectly coordinated rhythm, a condition known as dyssynchrony.

The effective medication strategy. Patients with heart failure whose imaging tests reveal an ejection fraction below 40 percent should be put on heart-failure medications such as ACE inhibitors, beta blockers, and diuretics, according to the AHA guidelines. "These medications have been shown to be absolutely critical, among the most important factors in determining whether patients will die or be rehospitalized in 60 or 90 days," says Gregg Fonarow, a professor of cardiovascular medicine at UCLA School of Medicine who chaired the AHA guideline committee. Along with these medications, African-American patients should be offered hydralazine-nitrate therapy to cut their mortality risk by an additional 43 percent, says Fonarow. "Yet fewer than 1 in 5 African-Americans who qualify for this treatment are actually getting it," he adds. Women, too, are less likely to be given guideline-indicated therapies. What's worse, research on heart-failure treatments in women is still lagging behind research in men, says cardiologist Nieca Goldberg, director of the women's heart center at New York University Medical Center. Currently the AHA guidelines recommend the same medications for women and men, but that, says Goldberg, may be the result of a lack of studies focusing on discerning gender differences.