Author + information
- Published online December 25, 2017.
- Marc A. Silver, MD∗ ()
- Department of Medicine/Division of Medical Services, Advocate Christ Medical Center, Oak Lawn, Illinois
- ↵∗Address for correspondence:
Dr. Marc A. Silver, Department of Medicine, Division of Medical Service, University of Illinois at Chicago, Advocate Christ Medical Center, 4440 West 95th Street, Suite 131 NOB, Oak Lawn, Illinois 60453.
Well, I won't back down
No, I won't back down
You can stand me up at the gates of hell
But I won't back down.
—Tom Petty (1)
For everyone who works in the heart failure space, our goals are fairly straightforward. If we have missed the opportunity for stage A or B heart failure prevention then our focus becomes survival, avoidance of emergency visits or acute care hospitalization, symptom improvement and stabilization, disease mastery, and life quality (2). With those goals in mind, we then set about deploying the fullest anti–heart failure armamentarium we can, including evidence-based drugs and devices, nutritional support, education, exercise, and tools to improve health literacy and chronic disease mastery skills.
But wait, there is another goal often overlooked in our patients who are heterogeneous in disease phenotype, gender, and age. Considering age, one also needs to understand the patient’s prior and current and desired role in the workforce. For the younger patient who has an acute myocardial infarction, considering resumption of life’s routines including sexual activity and re-engagement in the workforce is typically already on our checklist. However, for many of our patients, their progressive, insidious heart failure symptoms have already removed them from the workforce, or, commonly, their disease onset occurs once already retired from the workforce.
In this issue of JACC: Heart Failure, Rørth et al. (3) from Denmark explore a relationship between evidence-based drug therapy being taken at 1 year after an index heart failure admission and the rate of “workplace withdrawal” at the end of 3 subsequent years. Multiple questions go unanswered in this report and hopefully will be addressed in further work from this group and other. Still, it is worth examining the topic the authors are probing to guide us going forward.
What Do We Know About the Patients and the Study Conduct?
• The patients were from an original cohort of 24,239 patients hospitalized between 1997 and 2014 and eventually analyzed 10,185 patients who were in the workforce at 1 year after the index hospitalization for heart failure and 7,561 were on at least 1 component of evidence-based medicine (EBM) (74%).
• They were age 18 to 60 years of age with an average age of 52 to 53 years.
• They were predominantly men.
• Workforce detachment was defined as 3 consecutive weeks of paid sickness leave, early retirement, or other economic support from the state due to reduced working capability. Educational leaves, paid maternity leave, vacations, and others were considered to still be in the workforce.
• No patients became eligible for “ordinary retirement pension” (age 65 years in Denmark) during their time in the study.
• Evidence-based drug therapy was focused on use of renin-angiotensin system inhibitors and beta-blockers. They also looked at the use of mineralocorticoid receptor antagonists and loop diuretics, but the doses of the latter 2 drugs were not used in the calculation of the EBM score.
• The scoring basically assigned a fractional score of optimal dosing for renin-angiotensin system inhibitors or beta-blockers. The scores were summed and 4 cutpoints determined. The doses were those the patient was taking at 1 year after their index hospitalization.
• Several additional sensitivity analyses were done to evaluate, for example, EBM down-titration within the first year (approximately 5% of the population).
What Important Information Is Missing?
• Missing is key information regarding the patients’ phenotype, echocardiographic findings, vitals, functional status, target organ function, and biomarkers, all of which have the potential, as we know, to modulate individual EBM dosing.
• Further, we do not know what may have happened to EBM dosing in the remainder of the study (years 2, 3, and 4). Nor do we know about who followed the patients (primary care vs cardiology vs specialized nursing teams), frequency or intensity of heart failure follow-up, and education content or participation in exercise or nutritional counseling.
• Finally, it is difficult to assess the overall cultural impact of mores and customs (especially gender and age) regarding remaining in the workforce in Denmark compared with other industrialized nations.
What Is the Learning?
Several items are redundant of current knowledge of therapy for heart failure patients, including undertreatment with EBM being commonplace. Within the first year of therapy, doses often decrease. Also, patients followed in an “outpatient clinic” were more often closer to target doses of EBM. And finally, the point of this investigation, that the use of EBM beyond year 1 at or near target doses seems to provide another benefit—less workforce detachment. There are some signals that target doses interacts importantly with education, age, and gender. Diuretics, or perhaps the need to manage volume and/or symptoms with diuretics, again seem to have some correlation with workforce detachment.
The true learning, however, I believe, is that for most, if not all of our patients we need to be sensitive to their risk of “detachment” in general. It may be workforce, or family, or going to church or the market, or simply engaging in daily activity forms of detachment. We must add engagement or re-engagement of the patient into their community to a goal for all of our patients with heart failure. Similarly we need to be vigilant in making sure patients reach target doses of their EBM and understand the ubiquitous “creep” away from target doses of life-saving therapies. Getting our patients onto EBM is not the metric that will bring them success—rather, it is recognizing that the real metric is lifelong maintenance of EBM measures at or near target doses. We need to learn where and why this “creep” takes place and counteract these forces whether they are economic, lack of education, training or understanding by providers, patients or families, or whether it is simply the curse of chronic diseases—chronicity and complacency.
Finally, we need to understand that workplace withdrawal is not trivial, but rather impactful on individual and their families and communities as well as on a country’s economy. To these ends, we also need to know how to better assess the potential barriers to the patient’s ability to re-join the workforce. Understanding the larger powerful drivers of workplace withdrawal such as depression, perceptions that a diagnosis of heart failure means lifelong disability or even stigmas that persist in the workplace for anyone who has health issues.
We need to identify the toolkit needed to assess workplace re-engagement readiness and fitness for duty. This toolkit needs to be simple, easy to apply, and meaningful and convincing to patients, families, and employers. And we, as health care providers, need to be strong advocates for workforce re-engagement for our patients using EBM at or near target doses, not backing down from these life-saving therapies and perhaps, most important, understanding that in the end workplace and societal engagement may be one of the most important goals we should have for our patients.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Silver has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- ↵The essence of quotations. Tom Petty quotes. Available at: https://www.quotesandsayings.com/general/tom-petty-quotes/. Accessed October 19, 2017.
- ↵Colucci WS, Gottlieb SS, Yeon SB. Overview of the therapy of heart failure with reduced ejection fraction. Up To Date. 2017. Available at: https://www.uptodate.com/contents/overview-of-the-therapy-of-heart-failure-with-reduced-ejection-fraction. Accessed October 11, 2017.
- Rørth R.,
- Fosbøl E.L.,
- Mogensen U.M.,
- et al.