Author + information
- Received February 3, 2017
- Revision received April 13, 2017
- Accepted April 25, 2017
- Published online August 28, 2017.
- Amrut V. Ambardekar, MDa,∗ (, )
- Jennifer T. Thibodeau, MD, MScb,
- Adam D. DeVore, MDc,
- Michelle M. Kittleson, MD, PhDd,
- Rhondalyn C. Forde-McLean, MDe,
- Maryse Palardy, MDf,
- Maria M. Mountis, DOg,
- Linda Cadaret, MDh,
- Jeffrey J. Teuteberg, MDi,
- Salpy V. Pamboukian, MD, MSPHj,
- Rongbing Xie, MPHj,
- Lynne W. Stevenson, MDk and
- Garrick C. Stewart, MDk
- aDivision of Cardiology, University of Colorado, Aurora, Colorado
- bDepartment of Internal Medicine and Cardiology, University of Texas Southwestern, Dallas, Texas
- cDivision of Cardiology, Duke University Medical School, Durham, North Carolina
- dDivision of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
- eDepartment of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- fDepartment of Internal Medicine and Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
- gDivision of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
- hDivision of Cardiology, University of Iowa, Iowa City, Iowa
- iHeart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- jDivision of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama
- kDivision of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Amrut V. Ambardekar, Division of Cardiology, University of Colorado, 12700 East 19th Avenue, Campus Box B-139, Aurora, Colorado 80045.
Objectives This study assessed patient and physician perceptions of heart failure (HF) disease severity and treatment options.
Background The prognosis for ambulatory patients with advanced HF on medical therapy is uncertain, yet has important implications for decision making regarding transplantation and left ventricular assist device (LVAD) placement.
Methods Ambulatory patients with advanced HF (New York Heart Association functional class III to IV, Interagency Registry for Mechanically Assisted Circulatory Support profiles 4 to 7) on optimized medical therapy were enrolled across 11 centers. At baseline, treating cardiologists rated patients for perceived risk for transplant, LVAD, or death in the upcoming year. Patients were also surveyed about their own perceptions of life expectancy and willingness to undergo various interventions.
Results At enrollment, physicians regarded 111 of 161 patients (69%) of the total cohort to be at high risk for transplant, LVAD, or death, whereas only 23 patients (14%) felt they were at high risk. After a mean follow-up of 13 months, 61 patients (38%) experienced an endpoint of 33 deaths (21%), 13 transplants (8%), and 15 LVAD implants (9%). There was poor discrimination between risk prediction among both patients and physicians. Among physician-identified high-risk patients, 77% described willingness to consider LVAD, but 63% indicated that they would decline 1 or more other simpler forms of life-sustaining therapy such as ventilation, dialysis, or a feeding tube.
Conclusions Among patients with advanced HF, physicians identified most to be at high risk for transplantation, LVAD, or death, whereas few patients recognized themselves to be at high risk. Patients expressed inconsistent attitudes toward lifesaving treatments, possibly indicating poor understanding of these therapies. Educational interventions regarding disease severity and treatment options should be introduced prior to the need for advanced therapies such as intravenous inotropic therapy, transplantation, or LVAD.
- advanced heart failure
- cardiac transplantation
- mechanical circulatory support
- patient decision making
- ventricular assist device
This project was funded by National Institutes of Health/National Heart, Lung, and Blood Institute grant HHSN268201100025C and Board of Trustees of the University of Alabama at Birmingham. Dr. Ambardekar is supported by a Scientist Development grant from the American Heart Association and by Boettcher Foundation’s Webb-Waring Biomedical Research Program. Dr. DeVore has received support from the American Heart Association, Amgen, Maquet, Novartis, and Thoratec; and is a consultant for Maquet. Dr. Teuteberg has received speakers honoraria from HeartWare, Abiomed, and CareDx; and has financial relationships with Thoratec and Sunshine Heart. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 3, 2017.
- Revision received April 13, 2017.
- Accepted April 25, 2017.
- 2017 American College of Cardiology Foundation