Should I see a specialist for heart failure?

One of the most important decisions you will make after you have been diagnosed with heart failure is whom you choose to be your doctor. Your doctor will confirm the diagnosis and design a treatment plan for your heart failure and will be responsible for monitoring the progression of the disease and the effectiveness of the treatments. It is very important that you choose a doctor who is qualified to manage your heart failure. It is also important that you have a doctor with whom you feel comfortable sharing information about your symptoms and experiences.

What types of doctors can treat heart failure? All medical doctors have some knowledge about how to diagnose and treat heart failure. Doctors who treat people with heart failure include:

• General practitioners (GPs) and family medicine physicians (FMPs) have a working knowledge of the entire human body and the diseases that affect it. They treat a variety of people, including children, adolescents, and adults. GPs and FMPs usually work in outpatient clinics or their own offices and not usually in hospitals. At first a GP or FMP may diagnose and treat your heart failure. However, for more serious and complicated heart failure, your GP or FMP may start treating you and then refer you to a specialist who may be more qualified to treat your condition.
• Internists. Your primary care doctor may also be an internal medicine doctor (internist). An internist has completed several years of advanced training in the medical management of diseases that affect all of the organs of the body. Unlike GPs who often treat children and adolescents, internists usually limit their practices to adults. If the doctor you regularly visit is an internist, he or she may supervise your treatment after referring you to a cardiologist for specialized testing. An internist is qualified to manage the treatment of mild to moderately severe forms of heart failure and may do so just as successfully as a cardiologist.
• Cardiologists are doctors who specialize in diseases that affect the heart and blood vessels. Cardiologists first train to be internists and then do several additional years of training in cardiovascular disease. This additional training qualifies them to manage and treat diseases such as heart failure, coronary artery disease (CAD), and high blood pressure (hypertension). As your heart failure progresses, a cardiologist will probably play a large role in your treatment. After a diagnostic consultation, your cardiologist will discuss your care with your primary care doctor. In some cases your doctor will ask the cardiologist to confirm the diagnosis and the treatment plan but then will continue to take care of your heart failure. If heart failure is more severe or complex, you might continue to see your usual doctor for general medical care but see a cardiologist regularly for care of your heart.
• Heart failure specialists. Certain cardiologists specialize in heart failure. In addition to their training in general cardiology, these doctors have received specialized training in taking care of people with advanced heart failure and people who require or have received heart transplants. As heart failure worsens, your general cardiologist may refer you to one of these subspecialists. Heart failure specialists usually are familiar with and have access to the most advanced therapies for heart failure, including experimental treatments.
• Cardiac surgeons. If your cardiologist decides that your condition requires surgery, your cardiologist will refer you to a cardiac surgeon. Cardiac surgeons can specialize in many different types of heart surgery, such as coronary artery bypass graft (CABG) surgery or heart transplant. Cardiac surgeons can also repair or replace faulty heart valves. You generally will see a cardiac surgeon for a relatively brief period of time before and after the operation and will continue to see your cardiologist and your primary care doctor for your ongoing care.

In the treatment of heart failure, there will be a relationship between your primary care doctor and the doctors who specialize in treating your heart (specialists). Each type of doctor has a unique set of skills and may play a specific role in the management of your disease. Your initial tests to diagnose heart failure will probably be ordered by a primary care doctor, but some of these tests may need to be performed or interpreted by a cardiologist. Your primary care doctor may be a general practitioner.

Which type of doctor is the best for me? Internists and cardiologists are the two most common types of doctors responsible for treating heart failure. Cardiologists usually focus on treating people with more severe forms of the disease. The needs of each person with heart failure are different based on factors such as the cause of heart failure, the severity of the disease, and the age of the person. Recently there have been a number of studies that compare how well internists manage heart failure treatments compared with cardiologists. Some evidence suggests that cardiologists may achieve better outcomes in treating heart failure.

• Is a cardiologist best for me? One study suggested that people with coronary artery disease or heart failure who are treated by cardiologists appear more likely to receive evidence-based care and probably have better outcomes.¹
• Is an internist best for me? On the other hand, there may be some advantages in going to an internist to treat heart failure. First, your internist is likely to always be more familiar with the details of your medical history because he or she has managed each of your medical problems over the years. Second, you may feel more comfortable with your primary doctor because of this long-term relationship and therefore you may be able to work together more efficiently and productively. Third, if you see your internist for all of your care, he or she may be better able to optimize and balance the treatment of all of your medical problems, not just heart failure.

What other types of health professionals treat heart failure? In recent years, many physician practices have employed nurse practitioners (NPs) and physician assistants (PAs) to help in the care of people with heart failure. These health professionals have undergone advanced training in many aspects of general medicine. They extend the level of care a doctor can provide because they can evaluate and treat many of the routine problems that arise in people with heart failure. When more complex decision-making is required or when the severity or complexity of the problems surpasses the usual, NPs and PAs then can consult with the heart failure specialist.

When is a cardiologist referral needed? Your primary care doctor will usually decide whether to refer you to a cardiologist for treatment of your heart failure. Most doctors agree that there are certain situations when people with heart failure should always be referred to a cardiologist; in these situations, the complexity of the heart failure requires a specialist's knowledge and attention.

If you fit into one of the categories below and your primary care doctor has not referred you to a cardiologist, you should discuss the possibility of a referral to a cardiologist. As heart failure progresses and approaches end-stage, some people should be seen by a heart failure specialist. Usually your general cardiologist will refer you, but your general physician may do so as well.

People who should usually be seen by a cardiologist include those with:

• Severe heart failure (class III or IV).
• Severely weakened hearts from heart failure (ejection fractions of less than 30%).
• Moderate or severe heart failure caused by coronary artery disease.
• Heart failure caused by heart valve conditions.
• Heart failure that is complicated by arrhythmias (especially ventricular tachycardia).
• Heart failure symptoms that have worsened despite treatment by a primary care physician.
• Acute flare-ups of heart failure symptoms that require hospitalization.
• Heart failure and who are in a hospital intensive care unit.

People who should usually be seen by a heart failure specialist cardiologist include those who:

• Are being considered for a heart transplant.
• Have had heart transplants.
• Have severe heart failure symptoms despite maximum doses of all standard drugs.
• Would benefit from enrollment in a research study or clinical trial of a new treatment.

Do all types of doctors cost the same? Many studies have suggested that treatment by a cardiologist is more expensive than treatment by an internist. This difference in cost is probably because cardiologists tend to order more tests and prescribe more aggressive treatments. Additional tests and treatments both add to total cost and result in longer hospital stays.

Citations

1. Go AS (2000). A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. American Journal of Medicine, 108(3): 216–226.