Advanced CHF docs?

[chessknt]

I have noticed that the cardiologists in my location do not seem very good at managing critically ill patients in heart failure (eg cardiogenic shock, end stage CHF). I see tiny doses of lasix, no comments on inotrope or pressor support strategies, no mention of ECMO. I figured the interventional/general cards people get a pass on this because this isn't really their area but there are a few fellowship trained advanced CHF guys who also do not seem to do this very well either. They hold the keys to Impella and other assist devices but again on the medical management side I am often left to my own devices. Where I trained the advanced CHF fellows were part of the ICU team and would often direct the inotropes/pressors in these patients in addition to working with their mechanical support devices.

I guess I am wondering is this typical? Do you guys get the cardiologists involved in these patients routinely and have them actually help? I feel comfortable managing advanced CHF and often get them involved for CYA reasons and for an extra set of expert eyes and to help me argue for mechanical support but I have more often than not been pretty disappointed by their involvement. The general cardiologists will actively try to kill these patients sometimes by starting them on beta blockers for compensatory tachycardia or stopping my nipride to start an acei and that is something I just have to live with but I expected more from the CHF guys... Maybe I shouldn't be involving them because it is outside their area?

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[cardsperson]

I have noticed that the cardiologists in my location do not seem very good at managing critically ill patients in heart failure (eg cardiogenic shock, end stage CHF). I see tiny doses of lasix, no comments on inotrope or pressor support strategies, no mention of ECMO. I figured the interventional/general cards people get a pass on this because this isn't really their area but there are a few fellowship trained advanced CHF guys who also do not seem to do this very well either. They hold the keys to Impella and other assist devices but again on the medical management side I am often left to my own devices. Where I trained the advanced CHF fellows were part of the ICU team and would often direct the inotropes/pressors in these patients in addition to working with their mechanical support devices.

I guess I am wondering is this typical? Do you guys get the cardiologists involved in these patients routinely and have them actually help? I feel comfortable managing advanced CHF and often get them involved for CYA reasons and for an extra set of expert eyes and to help me argue for mechanical support but I have more often than not been pretty disappointed by their involvement. The general cardiologists will actively try to kill these patients sometimes by starting them on beta blockers for compensatory tachycardia or stopping my nipride to start an acei and that is something I just have to live with but I expected more from the CHF guys... Maybe I shouldn't be involving them because it is outside their area?

Your average interventionalist sees more cases of cardiogenic shock in a week than you do all month. And the reason why your CHF docs aren't rushing to put every chronic heart failure patient on VA ECMO is because they know the data pretty well - which is to say, survival is abysmal. As for beta-blockers and ACE inhibitors, we have decades of trial data now showing that these improve mortality in HFrEF, while no such data exists for nipride. Compensatory tachycardia is great when you have a healthy heart that can reach those heart rates without infarcting its own tissue, or going into VT storm - risks that are real in cardiogenic shock patients. I'm guessing it blows your mind when CHF docs put a patient on both milrinone and a tiny dose of metoprolol

 

[chessknt]

Your average interventionalist sees more cases of cardiogenic shock in a week than you do all month. And the reason why your CHF docs aren't rushing to put every chronic heart failure patient on VA ECMO is because they know the data pretty well - which is to say, survival is abysmal. As for beta-blockers and ACE inhibitors, we have decades of trial data now showing that these improve mortality in HFrEF, while no such data exists for nipride. Compensatory tachycardia is great when you have a healthy heart that can reach those heart rates without infarcting its own tissue, or going into VT storm - risks that are real in cardiogenic shock patients. I'm guessing it blows your mind when CHF docs put a patient on both milrinone and a tiny dose of metoprolol

See I know the first statement isnt true because I round on every patient in the icu even if I am not on the case per unit policy.

Nobody is arguing that acei/bb doesn’t work for hfref I am talking about bloated cold shock patients with trouble mentating… what data do we have in helping those people survive that outside of clinical consensus? You are telling me that a meth patient with hr 140s ef 15% cold needs beta blockers to ‘target hr <120’)? I have yet to see a single one of my chf docs use milrinone in the icu. Again I am no longer in academia these are community cardiologists many of which are 10+ years out from training but even the chf trained ones seem to do very little beyond a dribble of dobutamine and a lasix drip which I can honestly do just fine without them.

I am wondering if this is typical or if I just had a very different training experience where chf docs actually did something in the icu.

 

[Radetzky]

The second poster must be joking. Milrinone and metoprolol is an attempt at an assassination.

 

[aafisahar]

90-95% of the time milrinone and dobutamine are palliative options. If someone is that poorly compensating, they need a transplant, LVAD, or hospice. At that point, whatever you do is rearranging chairs on the titanic.

I agree that you should try to give them their best shot and decongesate them, but in my brief experience, it doesn't really matter in most cases. They'll fill right back up even with home inotropes.

I've noticed a trend in Lasix usage as well. The old House of God era physicians will slam folks with Lasix while physicians trained in the 90s to 2000s seem to think Lasix is a necessary evil. I hope the pendulum swings back because sometimes you need 200mg IV to make someone pee. That's just my observation from two places in training.

 

[turkeyjerky]

90-95% of the time milrinone and dobutamine are palliative options. If someone is that poorly compensating, they need a transplant, LVAD, or hospice. At that point, whatever you do is rearranging chairs on the titanic.


I agree that you should try to give them their best shot and decongesate them, but in my brief experience, it doesn't really matter in most cases. They'll fill right back up even with home inotropes.

I've noticed a trend in Lasix usage as well. The old House of God era physicians will slam folks with Lasix while physicians trained in the 90s to 2000s seem to think Lasix is a necessary evil. I hope the pendulum swings back because sometimes you need 200mg IV to make someone pee. That's just my observation from two places in training.

Honest Q—by palliative, do you also mean temporizing?

 

[CCM-MD]

Firstly, our cardiologists have a hard time accepting the heart is the problem most of the time for anyone in the unit. End stage CHF management is the opposite of lucrative and has bad outcomes, and as such it is not something our cardiologists are interested in being too involved with. We don’t have a advanced CHF doc. If transplant/VAD candidates, we try to transfer out. If not, we play around with inotropes/bb/acei/diuretics until they decide to go palliative or decompensate further and die in the unit.

 

[SurfingDoctor]

Firstly, our cardiologists have a hard time accepting the heart is the problem most of the time for anyone in the unit. End stage CHF management is the opposite of lucrative and has bad outcomes, and as such it is not something our cardiologists are interested in being too involved with. We don’t have a advanced CHF doc. If transplant/VAD candidates, we try to transfer out. If not, we play around with inotropes/bb/acei/diuretics until they decide to go palliative or decompensate further and die in the unit.

This warms me right in the cockles... which according to my neighborhood pediatric cardiologist, is also not a part of the heart.

 

[lymphocyte]

Your average interventionalist sees more cases of cardiogenic shock in a week than you do all month. And the reason why your CHF docs aren't rushing to put every chronic heart failure patient on VA ECMO is because they know the data pretty well - which is to say, survival is abysmal. As for beta-blockers and ACE inhibitors, we have decades of trial data now showing that these improve mortality in HFrEF, while no such data exists for nipride. Compensatory tachycardia is great when you have a healthy heart that can reach those heart rates without infarcting its own tissue, or going into VT storm - risks that are real in cardiogenic shock patients. I'm guessing it blows your mind when CHF docs put a patient on both milrinone and a tiny dose of metoprolol

I can't tell if this is meant to be a joke.

There are no good data about using beta-blockers in the acute setting, and there are lots of good data supporting nitroprusside in advanced low output failure states (like everything Cleveland Clinic has put out).

Our interventionalists see a lot of cardiogenic shock but generally stay in the cath lab. They don't play a role in managing these patients day to day.

Milrinone and metoprolol?

 

[chocomorsel]

Milrinone and metoprolol makes sense to me. How are you going to increase your cardiac output if the tachycardia is severely impeding your filling time?
What I find cardiologists having a difficult time with is Right heart failure.
Other than that, I find the ones I have dealt with to be helpful.
Someone with a HR in the 140s and an EF of 15% is going to end up crumping if you don’t do something to increase contractility and decrease the HR. What’s happening with the pulmonary edema at that point? Again, filling time is important. Diurese, after load reduction, whatever you need to do to decrease the workload of the heart. Milrinone and B blocker is not something I would consider absurd.

 

[aafisahar]

Honest Q—by palliative, do you also mean temporizing?

Sure, temporizing, palliative, both get at the bigger picture that you can't make them any better. End stage CHF is basically metastatic cancer. And if they are in the ICU, it's just like the refractory myeloma on 2 pressors and sucking on the vent. The endstage CHF guy looks better but unless he gets a VAD or transplant, it really doesn't matter what combination of meds and diuretics you use. It's all going to fail, whether it's in the unit, on the floor, or at home.

 

[RemyMcswain]

I do inter disciplinary critical care. I get your point, i think. The majority of general cardiolgists I interact with in the ICU really do not feel comfortable with the multidimensional shock, Titrating vasopressors/inotropes, interpreting swan numbers, performing focused TTE/US themselves, interplay of ventilator pressures etc that sort of defines "critical care." That is not a knock on the cards attendings I work with. I just think there is a difference between the intensivist who is sort of glued to the unstable ICU patient vs the cards consultant who writes "wean vasopressors".

Clearly the IC is actively involved in saving someones life when they acutely manage their shock in the cathlab. At my hospital, those docs never round. The general cardiolgist sees those patients. The actual management of shock is left to the intensivist and the general cards attending. Again, these are the attendings who would rather be doing an outpatient nuclear stress than sitting down and seeing how our PEEP titration effected LVOT VTI variability in the setting of a negative 500cc fluid balance

 

[aafisahar]

I do inter disciplinary critical care. I get your point, i think. The majority of general cardiolgists I interact with in the ICU really do not feel comfortable with the multidimensional shock, Titrating vasopressors/inotropes, interpreting swan numbers, performing focused TTE/US themselves, interplay of ventilator pressures etc that sort of defines "critical care." That is not a knock on the cards attendings I work with. I just think there is a difference between the intensivist who is sort of glued to the unstable ICU patient vs the cards consultant who writes "wean vasopressors".

Clearly the IC is actively involved in saving someones life when they acutely manage their shock in the cathlab. At my hospital, those docs never round. The general cardiolgist sees those patients. The actual management of shock is left to the intensivist and the general cards attending. Again, these are the attendings who would rather be doing an outpatient nuclear stress than sitting down and seeing how our PEEP titration effected LVOT VTI variability in the setting of a negative 500cc fluid balance

My perspective is that unless it's something acutely reversible (eg STEMI, someone awaiting surgical intervention, reversible cardiomyopathic) or someone with a long-term plan (transplant, VAD) then it doesn't really matter. Given that I may have 20+ consults to see, I can't afford to use hours to rearrange chairs on the Titanic. Furthermore, if you are doing fancy things like you mentioned and they are an advanced therapies candidate, it's time to bite the bullet and get him on the circuit. Otherwise, it's just making the numbers pretty for St Peter.

 

[chessknt]

My perspective is that unless it's something acutely reversible (eg STEMI, someone awaiting surgical intervention, reversible cardiomyopathic) or someone with a long-term plan (transplant, VAD) then it doesn't really matter. Given that I may have 20+ consults to see, I can't afford to use hours to rearrange chairs on the Titanic. Furthermore, if you are doing fancy things like you mentioned and they are an advanced therapies candidate, it's time to bite the bullet and get him on the circuit. Otherwise, it's just making the numbers pretty for St Peter.

That seems intellectually lazy but if that is truly the case write it in a consult and explain it to the family. Tell them you think hospice is appropriate and there is no meaningful chance of recovery. Don’t just have the mid level write continue pressors in a progress note with 35 mins of cc time unchanged from yesterday like my docs do.

 

[CCM-MD]

That seems intellectually lazy but if that is truly the case write it in a consult and explain it to the family. Tell them you think hospice is appropriate and there is no meaningful chance of recovery. Don’t just have the mid level write continue pressors in a progress note with 35 mins of cc time unchanged from yesterday like my docs do.

That type of abuse of critical care time billing pisses me off.

 

[RemyMcswain]

My perspective is that unless it's something acutely reversible (eg STEMI, someone awaiting surgical intervention, reversible cardiomyopathic) or someone with a long-term plan (transplant, VAD) then it doesn't really matter. Given that I may have 20+ consults to see, I can't afford to use hours to rearrange chairs on the Titanic. Furthermore, if you are doing fancy things like you mentioned and they are an advanced therapies candidate, it's time to bite the bullet and get him on the circuit. Otherwise, it's just making the numbers pretty for St Peter.

I get your point as well. If someone with ischemic CM and an EF of 15-20 comes in intubated in a HF exacerbation, one can just tread water with all the fancy ICU stuff. I agree, just decide whether that person needs a device or if they should go hospice.

I am more referring to the patient with something reversible. Something like cardiogenic shock with IABP and aspiration pneumonia + AKI etc. Those patients I notice that the cards attendings don’t really want to be involved despite the recent stent or IABP

 

[Blaughable]

Dear god this is frightening. Please transfer your patients to a center with a rigorous advanced heart failure program. But also thank you for the motivation to continue pursuing cards crit care.