Working with a Cardiologist

Occasions arise when a cardiologist’s expertise will change the diagnosis or theraptic approach. Consultation or referral to a cardiologist or HF specialty clinic should be considered for patients when the diagnosis is unclear, for patients who remain symptomatic on standard HF therapy, who have underlying valvular, pericardial, or infiltrative disease, or who have potentially reversible ischemic heart disease.

Patients may also benefit from comanagement with a cardiologist to assist with reaching target doses of an ACE inhibitor or initiating additional medications when such additions have proved difficult (beta-blocker). Cardiology consultation should

be considered for those with symptomatic atrial or ventricular tachyarrhythmias. In general, antiarrhythmic drugs should be avoided in HF patients because of their increased risk for causing sudden death. The primary care physician should also be considering

selected patients as candidates for cardiac transplantation; NYHA class IV patients have an annual mortality of 50%, whereas cardiac transplant patients have a 90% survival rate with improved quality of life. Patients who are refractory to maximal medical therapy and who do not have any contraindications to transplant should be sent to a regional cardiac transplantation center for evaluation. Contraindications to cardiac transplantation are advanced age (>70 yr); irreversible hepatic, renal, or pulmonary dysfunction; severe peripheral vascular or cerebrovascular disease; insulin-requiring diabetes mellitus with end-organ damage; active infection; recent cancer with uncertain status;psychiatric illness, with poor medical compliance; systemic disease that would significantly limit survival or rehabilitation; and pulmonary hypertension.