Diagnostic Algorithm for Heart Failure from Recent Guidelines

James Januzzi, MD: If I see a patient in the office and they have heart failure, I already know the path that they’re going to take with respect to the team that we have involved and how we evaluate them. Muthiah, you and I work in merged health systems now, but I would imagine that what happens on the east end of Boston is very different than what happens across town at the Brigham. I’m curious when you’re evaluating patients, in keeping with what the recent heart failure guidelines or telling us about the algorithm for heart failure, how do you approach them?

Muthiah Vaduganathan, MD, MPH: That team-based model is of central importance, we definitely approach even upfront on initial diagnosis, we approach patients as a team. We work together with clinical pharmacists to help with patient education around specific medications, as well as negotiating and navigating the various cost and access barriers to especially newer drug therapies. Furthermore, we work with our advanced practice providers who are critical to help follow up, accelerate care, and of course work with the broad network of trainees. This journey starts and is a long one, especially with multiple medical therapies. The starting point is this upfront discussion with a patient discussing the realities of heart failure, some of the core educational aspects, and that central to the treatment of heart failure now that it’s in place is multi drug regimens.

James Januzzi, MD: Absolutely. Education, education, education is just critically important. Let me scratch even further below the surface. Javed, when a person walks into the office to see you for the first time with heart failure, what are the tools that you use when you are meeting with them, elements of history, physical, laboratories, imaging, what are the basics?

Javed Butler, MD, MPH, MBA: The guidelines in that sense have really evolved and the earlier forms of guidelines are focused on treatment, but now we are thinking about the big picture. One issue is finding the right etiology, so it’s not only the accurate diagnosis of heart failure, but what is the etiology. There are some evaluations targeting etiology. The second is risk assessment and prognosis. There are lots of new recommendations that have come out for risk assessment, especially with natriuretic peptides. Natriuretic peptide had a class 1 recommendation for differential diagnosis of shortness of breath for a long time. Now if somebody gets hospitalized we are instructed or recommended to do a natriuretic peptide at the time of discharge for risk stratification, even in the chronic setting there’s a recommendation. Also, if somebody is at high risk for heart failure, doing it as an outpatient screening in of the natriuretic peptide levels are high, there are data that multidisciplinary teams working on risk factors can actually reduce the risk of heart failure. There’s a lot sort of around the natriuretic peptide level as well. You specifically mentioned the family history. Remember if you have a very proximate cause such as myocardial infarction and coronary artery disease, that’s one thing, but people who develop cardiomyopathy, and there’s really not an evident cause, genetic testing in that situation is important, and taking a 3-generation family history as well becomes important. The last thing that I will mention is that at the end of the day, physicians and nurses and clinicians, we are the coaches the patients are the players, and the patients cannot play well unless we coach them well. Patient education is very important, but we cannot coach them well till we understand the construct in which the patients are living. Their social determinants of health, their family history, the family environment, and just probing a little bit so that if there are things that we can uncover, that can potentially impact adherence or understanding why we’re doing what we’re doing and help them with those things can go a long way in improving outcomes for the patients.

James Januzzi, MD: That’s so critically important that we look beyond the prescription pad when we are thinking about our patients, because there are social determinants of health that exist outside the door of the exam room that we might not be aware of. Trying to understand those barriers to optimal care is just critically important, and indeed when you look at the projected epidemiology of heart failure in the future, we showed data that not only is heart failure going to increase by 30% to 35% in the United States, but it’s going to disproportionately affect populations that are vulnerable with substantial determinants to their health or lack thereof.

Transcript edited for clarity