SOURCE: Journal of the
American College of Cardiology (1997;30:725-732, 733-738)
An estimated 400,000 to 800,000 people in the U.S. have severe heart failure, and 200,000 people die of the disease
each year, according to the report in the Journal of the American College of Cardiology. Congestive heart failure is an
inability of the heart to pump blood, resulting in a buildup of fluid in the lungs and elsewhere in the body. It accounts for
about 1 million hospital admissions annually. "The average cost per hospital stay is $9,000, so half of this rate could
represent up to a $4.5 billion reduction in costs," reported lead study author Dr. Gregg Fonarow, of the Ahmanson
University of California at Los Angeles Cardiomyopathy Center.
The new study included 214 patients who were candidates for heart transplant. Over a six- month period, the patients
had a total of 429 hospital visits - an average of two visits per patient. Fonarow and colleagues used a more aggressive
heart failure treatment program, nearly doubling the patient's dosage of angiotensin-converting enzyme (ACE) inhibitor,
a drug that reduces the workload of the heart. And they adjusted the dose of diuretics - drugs that help reduce fluid
in the body - as well as counseled the patients about diet and exercise. In the next six months there were only 63 hospital
readmissions in the study group of patients, though 9 patients died, 14 underwent an emergency heart transplant and 12
had an elective transplant - not unexpected in a group of patients who were seriously ill and at risk for sudden death. The
patients who did survive showed an improvement in "functional status," that is, their heart was functioning better and
they showed an increased ability to exercise. "During the six months, only 26% of the 214 patients required hospital
admission, compared with 92% in the previous six months," the authors wrote. "The estimated savings in hospital
readmission costs after subtracting the initial hospital costs for management was $9,800 per patient." A program
specifically geared towards managing heart failure is more likely to use the most up-to- date procedures to treat patients.
Otherwise, physicians unfamiliar with the medication and dosage required to treat heart failure may be less aggressive
with available treatments.
A second study in the same issue of the journal appears to bolster that theory. Patients treated by general physicians
initially spent less time in the hospital and had fewer diagnostic tests but ultimately were 1.7 times more likely to require
readmission to the hospital compared with heart failure patients treated by a cardiologist. This was true even though the
cardiologists tended to treat patients that were sicker than those seen by a generalist, according to the study of 298
patients. The findings suggest that cardiologists should be involved in caring for patients with congestive heart failure,
concluded lead author Dr. Steven Reis, of the cardiology division at the University of Pittsburgh Medical Center in
Pennsylvania. "However, our results also suggest that congestive heart failure treatment guidelines need to be more
uniformly applied by all physicians caring for patients with heart failure," he concluded.