Congestive Heart Failure: Who Should Provide Care?

• Heart failure, congestive
• Ventricular dysfunction, left
• Practice guidelines
• Cardiology
• Specialties, medical

Chronic congestive heart failure with left ventricular systolic dysfunction has become a major health care challenge, both clinically and economically (1, 2). Clinically, congestive heart failure is a complex, heterogeneous disease process that afflicts more than 4.7 million patients in the United States, and more than 400 000 cases are newly diagnosed each year. The 6-year mortality rate associated with congestive heart failure approaches 80% in men and 60% in women. The impact of this disease on a patient's ability to maintain usual daily activities can be devastating. An estimated $38 billion is spent annually on care for congestive heart failure, of which $23 billion is spent on hospitalization.

The Agency for Health Care Policy and Research, the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the European Society of Cardiology have published guidelines for the evaluation and management of congestive heart failure (1-4). These evidence-based guidelines integrate inpatient and outpatient management strategies in a longitudinal fashion with the intent to improve survival and quality of life, decrease the need for hospitalization, and provide cost-effective care.

The guidelines initially direct attention to assessing and optimizing intravascular volume, assessing left ventricular function, identifying myocardial ischemia, and correcting mechanical lesions. Techniques for making these assessments include Doppler two-dimensional echocardiography, noninvasive measures to detect ischemic heart disease, and cardiac catheterization with coronary angiography to define potentially correctable coronary lesions or valvular disease. Treatment …