Advanced heart failure beckons: where are the cardiologists?

Abstract

Advanced Heart Failure is one of the leading causes of death and hospitalization worldwide. Its incidence is increasing steadily in India as well. Despite a huge need, not many cardiologists take heart failure as a career option. The present article seeks to explore the potential reasons for this lack of interest among cardiologists of the country. It also briefly attempts to suggest remedial actions.

Chronic heart failure, a relentlessly progressive disease, is a major cause of recurring hospitalization and mortality globally. India is also a victim of the ever-increasing burden of the disease. However, improved delivery of therapeutic options of acute coronary syndromes and acute heart failure reduces in-hospital and 30-day mortality but predisposes to subsequent chronic heart failure. The price of increased longevity seems greater for some due to progression to heart failure in them.

Despite significant improvements in medical treatment, heart failure continues to remain a progressive condition, leading to worsening of the heart function and degradation of the clinical status. The current estimates about the incidence of heart failure (HF) in India vary widely from 1.3 to 23 million [1]. Heart failure patients in India are a decade younger, have a greater incidence of diabetes, and are subject to higher in-hospital mortality compared with Western counterparts [2, 3]. Of this large heart failure population, approximately 10% suffer from advanced heart failure. Advanced heart failure is a clinical syndrome in which a patient has persistent and progressive symptoms despite guideline directed medical therapy (GDMT) [4]. At this stage, the clinical picture is gripped by severe symptoms, frequent episodes of decompensation, recurrent hospitalization, and poor quality of life (NYHA class 3B or class 4). The patient in advanced heart failure has progressed to a condition where traditional treatments are ineffective and advanced escalated tailored therapies such as mechanical circulatory support (MCS) and/or heart transplant become necessary. The patients in this phase are classified as stage D heart failure or end-stage heart failure [5]. These patients urgently need a referral to an advanced heart failure program to avoid further decompensation and multi-organ failure which may else render them ineligible for advanced therapeutic options.

India, on the verge of being a world capital of lifestyle diseases, is crippled by the lack of heart failure clinics. Limited cardiologists in the country have set up the required speciality clinics, making it imperative to ponder over the lackadaisical approach of the doctors toward the needs of these patients. Understanding the roadblocks in this arena is essential to better the delivery of care to this subset of patients having poor outcomes.

A lack of formal training can be considered a starting point. During the regular Doctorate of Medicine (DM) or Diplomate National Board (DNB) cardiology training, strong emphasis is laid on the treatment of rheumatic heart disease (RHD), valvular heart disease (VHD), and coronary artery disease (CAD). Undoubtedly, India still has a large proportion of patients suffering from these illnesses, yet equally important to note is that heart failure is the “final common pathway” in the natural/treatment history of these chronic diseases. Improved therapeutic options for RHD and CAD have been the most optimistic way forward but also do cause a proportionate increase in the heart failure patient population. Formal training is important because a cardiologist offering heart transplant options needs to have a reasonable knowledge of hemodynamics, immunology, and infectious diseases (ID) which unfortunately is not a part of most cardiology curriculums.

The young cardiologist looks for his role model during the early years of his professional growth. While interventional cardiology has a glorious plethora of role models to look up to, heart failure yet nascent has to grow its heroes. The far and few success stories are unable to stimulate the young cardiologist to opt for becoming the heart failure specialist. The loss of human life to heart failure despite best efforts by the treating cardiologist discourages the young doctors looking for success stories.

A large number of patients and rapid progression of the disease results in most of the heart failure patients seen by the same cardiologists or physicians who were treating their CAD or VHD. These treating physicians may lack the knowledge of the latest medical therapeutic options in heart failure, which results in an inability to achieve optimum GDMT. Even worse, once the patient reaches stage D advanced heart failure, early warning signs are frequently overlooked and a substantial number of patients reach palliative care stage without ever being offered the option of a heart transplant. This is frustrating for the heart failure cardiologist who never gets to see the most deserving patients despite the evidence that early referral may save the life of some of these patients. Similarly, patients too do not have awareness about the natural history of their disease and of all possible treatment options that are available today. Even when these patients are advised heart transplant, some find the option rather remote from real and those who do gather the knowledge of a possible transplant have a fear of the procedure in itself. As is true for most chronic disease treatments, patients prefer to seek another conservative opinion rather than give the real option serious consideration.

A heart transplant is solely dependent on deceased donor organ donation. While kidney and liver transplant programs have flourished due to living organ donation, heart transplant has lagged far behind since cadaveric organ donation is in its infancy at the best or non-existent in most parts of India. While Dr. P K Sen is credited to doing the first two heart transplants in India in as early as 1968, both patients died in the first few hours after surgery. After a prolonged hibernation, Dr. P Venugopal at All India Institute of Medical Sciences did the first successful heart transplant in India in August 1994 [6]. Up until 2010, yearly heart transplant numbers in India were usually limited to a single digit. (https://transtan.tn.gov.in/statistics.php, https://notto.gov.in) Encouragingly, the last 5 years have seen rapid growth, both in terms of the number of transplants and number of transplant centers. However, this growth in transplant numbers is led by only a few centers in Southern India (https://transtan.tn.gov.in/statistics.php) [7] and most other centers are still in single digits. Due to low numbers of patients referred for transplant and coupled with rapidly evolving advances in the transplant field, most cardiologists lose interest in the field and are unable to upgrade their knowledge. It is an extremely demanding and stressful field as one is dealing with very sick patients who require continuous supervision and delay in optimizing their care can have disastrous consequences for the patient. A successful advanced heart failure program is team dependent and every team member including the cardiologist, surgeon, anesthesiologist, immunologist, perfusionist, ID specialist, and nurses needs to be equally motivated.

India’s total healthcare spending (out-of-pocket and public) at 3.6% of Gross Domestic Product (GDP) is way lower than that of other countries. Thus, we cannot escape from highlighting the financial challenges posed in this disease. Advanced heart failure program is a very cost-intensive program. The hospital needs to invest in infrastructure, training of personnel, and procurement of drugs and devices for a small number of affording patients, thus making it even more cost-intensive. A majority of the patients lack adequate insurance and even further the insurance companies do not cover for these novel modalities. The government reimbursement scheme for the treatment of its employees also reimburses a miniscule or does not reimburse MCS implantation. As a result, very few patients who deserve these therapies as a life-saving measure can have access to them. This certainly lowers the morale of the motivated treating team and demotivates fresh cardiologists to consider this as a career option.

What needs to be done to ignite interest in cardiologists? For one, make therapy more affordable and widely available. Lack of affordability is a reality, yet many do not have access to therapy options due to lack of awareness. As any therapy becomes more widespread, it begins to become more affordable. To have an indigenous device is imperative to contain the expense of this therapy. The potential in our researchers and medical device industry is enormous. Second, we need to publish more original research papers and case reports to generate interest and awareness in our younger colleagues. Teaching curriculum should include training in the treatment of advanced heart failure and post DM/DNB fellowship should be commenced in this field where these fellows get exposed to treatment protocols of high-volume centers. Awareness drives like “pledge to donate organs” and Continuing Medical Education (CME) programs will boost the interest in more cardiologists to choose heart failure as a career option.

India needs more heart failure specialists to justify the needs of our patients.

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