Justin Vader, MD, a WashU Medicine cardiologist and heart failure specialist at Barnes-Jewish Hospital, often sees patients with heart failure who are so sick by the time they enter care at Barnes-Jewish Hospital, that they require extracorporeal membrane oxygenation (ECMO). Fortunately, the heart failure team is often able to stabilize such patients and transition them to a platform of support with a temporary heart pump, allowing patients to rehabilitate in the intensive care unit with the goal of either recovering cardiac function, undergoing a heart transplant or another procedure that may be appropriate for the patient’s needs.
Justin Vader, MD
Our heart failure team includes cardiologists, cardiac surgeons, electrophysiologists, interventional cardiologists and more. This multidisciplinary collaboration allows patients experiencing end-stage heart failure to achieve positive outcomes with the most effective therapies including surgery, implantation of left ventricular assist devices (LVAD) and cardiac transplantation. Although the scenario Vader described can have a positive outcome, patients experiencing heart failure require prompt attention and support, ideally, with early interventions before heart failure progresses and treatment options are limited. According to the Heart Failure Society of America, approximately 6.5 million people in the U.S. over the age of 20 have heart failure, and this number is expected to increase to more than 8 million by 2030.1 Early intervention for heart failure means patients have more treatment options and better quality of life. Barnes-Jewish Hospital is the only hospital within 200 miles of St. Louis to offer a full spectrum of heart failure and cardiomyopathy care integrated with other disciplines.
Keep in mind INEEDHELP when considering when to refer a patient to a Heart Failure Specialist:
- I – Use of intravenous inotropes
- N– New York Heart Association Class IIIB/IV or persistently elevated natriuretic peptides
- E – End-organ dysfunction (rising creatinine, worsening liver function)
- E– Left Ventricular Ejection fraction ? 20%
- D– Defibrillator shocks for ventricular arrhythmias
- H– Hospitalizations for heart failure (> 1 within the past year)
- E– Edema despite escalating diuretics
- L– Low blood pressure, high heart rate
- P– Progressive intolerance or down-titration of GDMT
When assessing a patient with heart failure, Vader first identifies the cause of heart failure to determine the treatment approach. The process of selecting a therapy is guided by advanced imaging, genetic testing and, in certain cases, invasive procedures. “Early and aggressive application of guideline-directed medical therapies for heart failure is well established in lengthening the survival of patients,” Vader says. “It’s one of the things that we pride ourselves on doing very well at the Washington University and Barnes-Jewish Heart and Vascular Center.”
Sumanth D. Prabhu, MD
Sumanth Prabhu, MD, a WashU Medicine cardiologist and heart failure specialist at Barnes-Jewish Hospital, emphasizes that understanding underlying causes of heart failure, such as amyloidosis, sarcoidosis, or hypertrophic cardiomyopathy, is critical. The identification of specific causes of heart failure can help with accessing targeted treatment, inclusion in clinical trials or enrollment in patient registries, leading to better outcomes. Beyond targeted therapies for specific cardiomyopathies (e.g., cardiac amyloidosis), current guidelines support the broad use of four classes of drugs that can improve patient outcomes in ischemic and non-ischemic cardiomyopathy with reduced ejection fraction - beta blockers, angiotensin receptor and neprilysin inhibitors (ARNI), mineralocorticoid receptor antagonists, and SGLT2 inhibitors. ACE inhibitors or angiotensin-receptor blockers can be considered as alternatives if ARNIs cannot be used.
Additional devices may be considered at different stages. Including:
- Carotid baroreflex stimulation devices
- Cardiac contractility modulation devices
- Implantable EP devices, which might include defibrillators and pacemakers
- Cardiac resynchronization therapy devices for patients with left bundle branch block or a nonspecific interventricular block that meets certain criteria on their ECG. These patients are treated in collaboration with the electrophysiology team.
- Implantable pressure sensors to monitor patients. If the device senses that the patient is progressing towards a heart failure that would require hospitalization, providers can intercede and optimize their therapy to avoid hospitalization.
In cases of heart failure, early intervention is key. Barnes-Jewish Hospital encourages referring physicians to reach out early for the best possible patient outcome, if you have a patient who might benefit from a referral to the Washington University and Barnes-Jewish Heart and Vascular Center, call 314-362-1291.
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