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When to Refer to a Heart Failure Specialist—Are You Waiting Too Long?

NOTE TO READERS: The questions in this activity are intended for self-reflection. Please complete the post-activity assessment and evaluation to record your responses and earn credit for completing this educational activity.

Heart failure (HF) is a complex disease process. Rarely can a single clinician provide optimal care without seeking advice, consultation with other members of the patient’s care team, and often referral to those with additional experience and training in HF. In every sense, asking for support and help are integral components of the concept of optimal care. Yet, we know that in real-world situations there are barriers to delivering optimal care. Many patients remain undertreated, regardless of whether they are hospitalized with HF or treated in the outpatient setting. Additionally, both patients and clinicians hope that a “wait and see” approach might provide some improvement, often delaying care and resulting instead in clinical worsening.1,2

Therefore, it is worth discussing several important questions clinicians have about obtaining consultation and referral with the goal of improving patient care.

Question 1. According to the I-NEED-HELP acronym, which high risk features of HF should alert the clinician to refer the patient to a HF specialist?

Explanation for Question 1 (Click to expand)


Perhaps the first barrier is who. Put another way, how can clinicians identify the patient who needs additional consultation or referral? Patients with advanced HF are typically identified based on symptoms plus laboratory test and diagnostic data (Figure 1).3 At the extreme, there are multiple guideline recommendations for identifying advanced HF.4-11 In addition, the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) criteria are useful for identifying patients who may require mechanically assisted circulatory support.6 (Click here to view a summary of the definitions and indicators of advanced HF recognized by the European Society of Cardiology (ESC), the ACCF/AHA, and INTERMACS.4-6)

The 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment included a simple acronym to assist clinicians in decision making for referral to an advanced HF specialist.12,13,14  This easy-to-remember acronym, I-NEED-HELP, represents high-risk features that should trigger consideration for referral to advanced HF care.

I-NEED-HELP: An Acronym to Assist in Decision Making for Referral to an Advanced HF Specialist12,13


IV (intravenous) inotropes


NYHA (New York Heart Association) IIIB/IV or persistently elevated natriuretic peptides


End-organ dysfunction


Ejection fraction ≤35%


Defibrillator shocks


Hospitalizations (>1)


Edema despite escalating diuretics


Low blood pressure, high heart rate


Prognostic medication—progressive intolerance or down-titration of guideline-directed medical therapies (GDMTs)

It is clear that the patients most likely to trigger additional consultation or referral are typically stage D (see Key Concept 2, below). The ideal scenario, however, is to identify these patients earlier on in their disease with the goal of applying lifesaving and disease-modifying strategies to slow the progression to this advanced stage.

Other situations for identifying patients in need of additional clinical expertise might include:

  • Consultation for creation of a plan that helps detail the next several strategies for care to be followed by the patient’s primary team
  • Patients not responding to or not tolerating “standard” treatments or who need uptitration to target doses of GDMT
  • Consideration for advanced HF therapies or emerging investigational therapies
  • Lack of time or experience in caring for patients needing a complicated HF therapeutic program
  • Patients who have comorbidities that complicate their care such as atrial fibrillation, chronic obstructive pulmonary disease, diabetes, coronary artery disease, or central or peripheral vascular disease. Also, patients who might be eligible for and benefit from devices to monitor or treat their HF (cardiac resynchronization or implantable cardioverter-defibrillator [ICD])
  • Patients who live remotely and are unable to be evaluated often enough to avoid frequent decompensation
  • Patients who have been poorly compliant and yet may benefit from team members who are experienced in working with such patients to help create a shift in their behaviors (ie, dieticians, exercise physiologists, psychologists, etc)
  • Communities without team members able to provide care

Perhaps the next barrier is not knowing when to obtain consultation. The question of “when” is more straightforward, and the answer, simply put, is whenever the need for help or guidance arises. Sometimes the opportunity for consultation arises when patients or families ask about other options or opinions. Other times, a consultation or referral may be initiated by the clinician.

Despite evidence that early referral improves HF outcomes, there are barriers to efficient implementation of the referral pathway. Many clinicians who manage patients with HF feel uncertain about key aspects of HF management. A qualitative evidence synthesis of published data regarding general practitioners’ (GPs’) perceptions of HF management in primary care was undertaken to identify barriers to optimal care.15 In this analysis, GPs expressed the desire for a multidisciplinary approach to HF care but reported mixed experiences with interprofessional collaboration. Uncertainties about clinical practice, how to implement evidence-based recommendations in practice, and how to work together within a multiprofessional team were identified as the main challenges of GPs providing HF care.

The challenges of collaboration were further brought to light in a recent study of referral times to a dedicated HF clinic for patients with a positive N-terminal pro-brain (B-type) natriuretic peptide (NT-proBNP) result in primary care.16 Significant delays between a positive NT-proBNP result and referral to a HF specialist were observed, including one delay of 124 days between the positive result and referral. These findings point to the need for improvements in collaboration and in timely referral to specialty care. The important point to remember is that it is in everyone’s best interests to seek help as early as needed, even if only to validate the current care plan.

The question of to whom is more difficult. Heart failure care has evolved over the last few decades from having few effective therapies and limited practitioners focusing on care of the patient with HF to having multiple therapies, many of which positively impact survival and prevent hospitalization. Also, there are now specific training and certification programs for physicians and nurses, so it is easier to identify those who have committed a large part of their practices and research efforts to HF care. However, despite the ever-increasing knowledge base of HF care, there are no boundaries to delineate who might have the interest, commitment, and knowledge to provide such care. Typically, these clinicians are well-known in the community and should be viewed as a valuable resource and as a useful expansion of the patient’s care team.

Question 2. When should the patient’s HF stage be evaluated?

Explanation for Question 2 (Click to expand)


In 2001 the ACC/AHA Heart Failure Guideline Committee introduced a very useful staging system that provides awareness and clarity on the natural progression of patients with HF.4 (See Figure below to view a schematic representation of stages and related treatment recommendations.) The basic purpose of the system is to help identify a patient’s current stage, to further identify stage-specific steps a clinician should take, and to reference therapies that might help slow or prevent progression to the next stage.

Some patients with only risk factors for HF such as hypertension, family history, or prior exposure to cardiotoxins (stage A) may remain in that stage for years. However, preemptive treatment is required.4 Transition to stage B is evident in patients with any degree of structural damage (eg, myocardial infarction, decline in left ventricular ejection fraction), and these patients have developed an accelerated path toward symptomatic and typically advanced HF (stages C and D, respectively) and must receive guideline-directed therapy and care.

The determination of the patient’s HF stage comes directly from a patient interview (history, records) and readily available diagnostics (eg, electrocardiograms, echocardiograms). However, there are tools to assist the clinician in evaluating and making sense of the many pieces of information needed to arrive at a decision as to the patient’s HF stage. Online tools, such as the MDCalc online ACC/AHA Heart Failure Staging tool (found at, can be a convenient adjunct to treatment guidelines.11

Ultimately, determination of the patient’s stage should become a routine, and HF stage should be carefully updated at each clinical interaction, shared with the patient, prominently displayed in the patient record, and communicated across the care team. The importance of doing so, of course, is that an advancing stage should be a red flag for the entire team and should trigger careful re-examination of the current care plan to look for gaps in care. This also should trigger a decision to seek consultation and/or referral as needed.

Question 3. What was a key finding of both the CHAMP-HF and CHECK-HF registries?

Explanation for Question 3 (Click to expand)


As HF is a complicated and systemic disease, gaps in care can appear in many areas. An area not carefully scrutinized is typically where a patient might fail, triggering a cascade of worsening HF. For example, a patient who is on medical therapy might fail due to a breakdown of the care team’s ability to identify and rectify poor diet, lack of exercise, or the presence of depression.13,14

More commonly, as mentioned above, therapies that are potentially disease-modifying and lifesaving may have been overlooked or underdosed. Two recently published registry studies, CHECK-HF in the Netherlands and CHAMP-HF in the United States, reported significant gaps in utilization of GDMT in the outpatient setting.17,18  Among patients receiving GDMT in the CHECK-HF registry, which included 5701 patients with heart failure with reduced ejection fraction (HFrEF) from 34 cardiology practices, rates of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), beta-blocker, and mineralocorticoid receptor antagonist (MRA) triple therapy varied greatly across practices, with 17% to 76% of eligible patients receiving this therapy.

Further, only 19% (patients on beta-blockers) to 52% (patients on MRAs) received their medication at target doses.17 The investigators also noted an association between older age and lower likelihood of receiving each type of GDMT. In the CHAMP-HF registry, which included 3518 patients from 150 cardiology and primary care practices in the United States, the investigators found that 27% of eligible patients were not prescribed ACEI/ARB/angiotensin receptor-neprilysin inhibitor (ARNI), 33% were not prescribed beta-blockers, and 67% were not prescribed MRA therapy. Among patients who were prescribed these drugs, fewer than one-third were receiving their medications at target doses.18 In the inpatient setting, similar variability in optimization of GDMT for hospitalized HF patients has been observed.19 These findings affirm the need for improvement in the quality of HF care in daily practice.

Another gap in care may occur when a potentially beneficial therapy has been considered contraindicated for a patient at one point in time. For example, following a round of increased diuretics for an exacerbation, the patient’s renal function may have become transiently impaired, leading the clinician to exclude multiple classes of therapeutic agents that could actually benefit the patient. The patient with HF is extremely dynamic in their physiology, even though HF might be readily apparent from a cursory questioning of symptoms.

A useful practical approach, especially if the patient’s status is not improving or is worsening, or if there are other laboratory or biomarker indicators of disease progression, includes:

  • Review of stage, functional status, and signs/symptoms at every encounter
  • Review of all current therapies, including identification of current dose relative to target doses
  • Look for therapies that might be contraindicated for a particular patient, such as nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Review past limitations with a particular therapy and consider updated circumstances and possibility of rechallenge
  • Consider consultation and/or referral for additional help to optimize that patient’s therapeutic profile

In summary, HF is a progressive and insidious disease state, and patients benefit most from a team-based approach; yet too often many of the needed team members work outside of an individual practice. There are many barriers to seeking consultation and referral. However, there are steps the clinician can take in evaluating the patient that will assist them in confidently taking the next step toward consultation and referral. Following this approach is in the best interests of the patient and leads to the best outcomes.

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