Preempting Stage A Heart Failure In Primary Care
JUNE 11, 2018
Vera Barton-Maxell, PhD, APRN, FNP-BC, CHFN
Vera Barton-Maxell, PhD, APRN, FNP-BC, CHFNPrimary care providers in ambulatory care settings see patients with heart failure (HF) daily. Most of these individuals are not established with cardiologists. The challenge is to identify these patients and aggressively address the risk factors that have put them in jeopardy for the only cardiovascular (CV) condition that remains on the rise in the United States.
The number of adults living with HF has increased from about 5.7 million (2009-2012) to about 6.5 million (2011- 2014).1 Hospital admission rates for patients with HF have increased approximately 150% over the past 2 decades. Estimated direct and indirect costs of HF in the United States total $39.2 billion. Despite advances in HF care and the emergence of evidence-based therapies (EBTs), morbidity and mortality rates remain unacceptably high, with all-cause mortality increasing after each hospitalization.
Hypertension (HTN) and coronary artery disease are the 2 most important causes of HF in the United States. To concentrate therapies on aggressive management of risk factors by identifying those most likely to develop HF and experience progressive disease, the American Heart Association (AHA), in conjunction with the American College of Cardiology (ACC), developed 4 stages of HF.2 The stages range from stage A, signaling a “high risk of developing HF,” to stage D, signaling “advanced HF,” and treatment plans are provided for each stage. Unlike the New York Heart Association’s functional classes, which are symptom-based and fluid, the AHA/ACC stages of HF are progressive and unidirectional. Once a patient has been staged, there is no going back. The best hope is for stagnation.
Stage A heart failure describes patients at high risk of HF who are without symptoms or evidence of structural heart disease. Stage A includes individuals with diabetes, HTN, metabolic syndrome, obesity, atherosclerotic disease, a family history of cardiomyopathy, or a personal history of cardiotoxin ingestion. Goals of therapy for stage A patients include a heart-healthy lifestyle and prevention of vascular and coronary disease and left ventricular (LV) structural abnormalities. Because these patients have already been identified as stage A, education about the importance of adherence to therapeutic lifestyle modifications, including exercise, weight loss, smoking cessation, and EBT regimens, should take on deserved urgency. Generally, 30 minutes of aerobic exercise 5 times per week is recommended. A heart-healthy diet needs to be individualized and culturally sensitive, emphasizing fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, and nuts and limiting sodium, red meat, saturated and trans fats, and sweeteners with sugar. Often, medications are required to achieve management goals. The use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers is appropriate for those with vascular conditions or diabetes. Statin therapy should be initiated and optimized when appropriate.
For those patients who have heart failure with reduced ejection fraction (HFrEF), morbidity and mortality can be significantly improved with evidence-based pharmaceutical and implantable device therapies. A reduced ejection fraction (EF) is usually defined as ≤40%. There are millions of Americans with borderline EFs who are not receiving appropriate therapy. Asymptomatic LV dysfunction (ALVD) in patients signals stage B heart failure, indicating that there is structural heart disease but no signs or symptoms of HF.3 Yet these patients are also often followed in primary care without aggressive management. Framingham data reveal that survival for those with even mild, sustained ALVD (EF between 40% and 50%) declines dramatically after diagnosis. Heart failure with preserved ejection fraction (HFpEF), formerly known as diastolic HF, accounts for 50% of the HF population. HTN that has not been optimally controlled is the primary cause of HFpEF. The commonly ignored finding on an echocardiogram of any level of diastolic dysfunction is a salient warning of impaired LV relaxation. Without optimal blood pressure (BP) control, progression to HFpEF is predictable. Unlike recommendations for treatment of HFrEF with a preponderance of EBT, to date, those for HFpEF concentrate on symptom management and prevention strategies, with optimal BP control being paramount.
Although the ACC/AHA 2017 guidelines for HTN highlight the need for proper methodology in monitoring and categorizing patients, as well as advocating the use of home BP monitoring, the take-home message is clear: Lower is better.4 Elevated BP is now defined as ≥120 to 129/<80 mm Hg with stage 1 HTN as 130 to 139 systolic or 80 to 89 mm Hg diastolic and stage 2 HTN as ≥140/90 mm Hg. A meta-analysis of 16 CV trials by Thomopoulos et al found that in those patients with increased CV risk (defined as age >75 years, with established vascular disease and chronic renal disease), a systolic BP of <120 mm Hg was associated with a significant decrease in HF and CV deaths.5
Patients with symptomatic HF and/or structural heart disease are best cared for in the expert hands of specialists in cardiology, HF, and electrophysiology. The best way to combat the HF epidemic is the prevention of progressive HF. Care of patients with stage A heart failure who deserve the hope for a long and healthy life without progression to advanced HF lies squarely in the realm of primary care.
AHA recommendations for a heart-healthy lifestyle can be found at heart.org
1. Benjamin EJ, Blaha MJ, Chiuve ML, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association.Circulation. 2017;135(10):e146- e603.doi:10.1161/CIR.0000000000000485.
2. Yancy CW, Jessup ML,Biyken B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2017;136(6):e137-e161. doi: 10.1161/CIR.0000000000000509.
3. Wang TJ, Evans JC, Benjamin EJ, Levy D, LeRoy EC, Vasan RS. Natural history of asymptomatic left ventricular systolic dysfunction in the community. Circulation. 2003;108(8):977-982.doi: 10.1161/01. CIR.0000085166.44904.79.
4. Whelton PK, Carey, RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines [published online November 7, 2017]. J Am Coll Cardiol.doi: 10.1016/j. jacc.2017.11.005.
5. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyses of randomized trials. J Hypertens. 2016;34(4):613-622.doi: 10.1097/ HJH.0000000000000881.