This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
"We've gotten so good at preventing patients with heart attacks from dying,
that now we have a growing group of survivors with damaged hearts," said John
Keaney Jr., MD, chief of cardiovascular medicine at UMass Memorial Medical
Center, noting that an estimated five million Americans are living with heart
failure today. "We need to bring resources to bear in caring for them in a way
that minimizes morbidity and mortality, and that's what our Advanced Heart
Failure Program is designed to do."
An integral part of the Advanced Heart Failure Program, the Heart Failure
Wellness Center (HFWC) was established in 1995 and is the only one of its kind
in the Worcester area. It provides comprehensive evaluation and treatment
resources on an outpatient basis and has an inpatient program for patients who
require hospitalization. The staff sees nearly 1,700 patients annually who
benefit from the center's proactive disease management strategy that includes
diagnostics, medication titration, surgery when appropriate, use of
technological monitoring devices and extensive education.
A team approach and constant surveillance
"Heart failure requires a team approach and constant surveillance and
monitoring," said Theo Meyer, MD, DPhil, medical director of the center, who has
more than 25 years of specialized experience in the diagnosis, assessment and
management of advanced heart failure patients. "Ongoing surveillance is
necessary to detect early signs of decompensation so that we can intervene to
prevent the condition from worsening and, ideally, avoid hospitalization."
In fact, more than one million hospitalizations occur every year in the
United States due to acute heart failure exacerbation, and it is estimated that
approximately half of these are for a subset of 200,000 patients who are
admitted at least twice per year.
One of the ways that the HFWC at UMass Memorial Medical Center provides
surveillance is through a state-of-the-art home telemonitoring program. Patients
are outfitted with a scale, blood pressure cuff and special electronic monitor
that transmit physiologic data daily via the web.
"Home telemonitoring is ideal for patients who are the sickest, or those with
limited social support or insight into their disease," noted Maggie Cabral, NP,
clinical coordinator of the Advanced Heart Failure Program. "Our staff is
familiar with these patients and their medical history. Reviewing information
daily enables us to intervene as soon as we see changes in their weight or
hemodynamics." About 20 patients currently are on the system.
Working closely with the electrophysiology service at the Medical Center, the
HFWC also is able to perform remote patient monitoring by downloading data from
implanted defibrillators and pacemakers used to synchronize the heart.
"Outcomes data shows that our outpatient surveillance system has decreased
hospitalization, with our readmission rates lower than the national average,"
said Dr. Meyer. "And when a patient is admitted to our inpatient service, the
length of stay is shorter. In terms of patients' quality of life as well as the
impact on resource utilization, this is significant."
Headed by Dr. Meyer, the Advanced Heart Failure Program team includes three
nurse practitioners with special training in heart failure who rotate between
the inpatient service and outpatient center. This design allows the staff to
follow patients in the acute phase of their illness as well as in the outpatient
setting. "Once discharged, we encourage our patients to maintain close
communication with us. A significant amount of time is spent triaging phone
calls and accommodating urgent visits if our patients become symptomatic," Ms.
Cabral said. "Intensive education, especially with newly diagnosed patients,
about lifestyle modifications and self management is another major focus of the
care we deliver."
"The team is well versed in the management of advanced heart failure, and we
have the resources to provide the optimal diagnostic and treatment strategy for
each patient," Dr. Meyer stressed. Diagnostic resources include on-site
echocardiography, BNP (B-type natriuretic peptide, a specific chemical marker of
heart failure) measurement, and impedance cardiography and device interrogation.
And in addition to medical management, the treatment options available at UMass
Memorial include surgical and percutaneous revascularization and
electrophysiology devices, such as pacemakers, implantable defibrillators and
An integrated cardiac transplant program
For patients requiring other advanced therapies, UMass Memorial Medical
Center established an integrated cardiac transplantation program with Tufts
Medical Center, which has performed heart transplants since 1985.
"With this integrated program, patients can be comprehensively assessed here
at UMass Memorial, go to Tufts for the operation, then come back here for
follow-up care," said Dr. Meyer. "It's a seamless system with great continuity
of care, and it's so much more convenient for patients here in Central
Massachusetts." (See accompanying sidebar for one patient's story.)
The Advanced Heart Failure Program also participates in ongoing clinical
trials, with several studies currently underway - giving appropriate patients
the opportunity to benefit from leading-edge research. One such study is testing
a pacemaker that incorporates a pressure lead with a pacing lead. This allows
continuous measurements of pressures in the blood vessels of the lung.
"The theory is that a week or two before a patient exhibits symptoms of
decompensation, there is an increase in the blood pressure in the lung,
predisposing to fluid leakage in the lung tissue," said Ms. Cabral. "It's hoped
that the pressure lead will detect the fluid changes before the patient has
symptoms so we can intervene and prevent episodes of decompensation and
A comanagement approach to working with referring
The Advanced Heart Failure Program receives referrals from both primary care
physicians and fellow cardiologists. An important concept is the center's
ability to comanage patients with the referring physicians. Referral to the
center does not necessitate a loss of involvement by the referring physician,
rather another resource that physicians can use in caring for this sick
population. "Our goal is to give patients individualized treatment, optimize
their care and provide whatever assistance is needed in maintaining their health
and well-being," said Ms. Cabral. Patients can be referred to the center for an
initial evaluation or "second opinion" or for ongoing follow-up and support per
the discretion of referring physicians.
"If there's one message I want to convey to the referring community, it's
that our collaborative team approach to caring for patients with heart failure
extends to them," said Dr. Meyer. "We have very good relationships with our
referring physicians to comanage these patients and to offer advanced therapies
"This is not only a place to which they can send patients for evaluation and
treatment," he added, "We are also a resource for doing some of the
time-consuming ‘labor' of phone management and fine tuning of medications. And
we're always here for advice."
To refer a patient on an urgent basis, Ms. Cabral encourages physicians to
call the HFWC's urgent access line at 508-579-5379. Urgent appointments for new
patients generally can be scheduled within 24 to 48 hours. For nonurgent
appointments, call the center's main number at 508-856-3452.