MP-6 - OUTCOMES IN HEART FAILURE PATIENT MANAGEMENT BY PRIMARY CARE PROVIDERS COMPARED WITH CARDIOLOGISTS; A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Heart failure (HF) is a global pandemic, associated with substantial resource utilization and healthcare costs. While the incidence of HF is stable, prevalence is increasing due to advances in medical therapy and improved life expectancy. Specialists do not have the capacity to manage all heart failure patients and thus most healthcare systems depend on primary care practitioners. HF outcomes for patients solely followed by primary care practitioners have not been well studied. We herein aim to evaluate differences in outcomes in patients with HF managed by cardiologists compared with primary care practitioners.

METHODS AND RESULTS: We conducted a systematic review of studies (observational and experimental) of adults receiving outpatient HF care by cardiologists compared with primary care providers. Outcomes included all-cause deaths, HF/cardiovascular disease deaths, HF hospitalization, readmissions rates, emergency department visits, and rates of HF medication use. We searched Embase, Cochrane Central Register, PubMed, and Web of Science for studies published 1946 to April 2023.

Nine studies were included, representing 35,528 patients, on average aged 67-75, enrolled between 1991 to 2012. Patients with higher NYHA functional class and lower ejection fraction were more likely to be followed by cardiologists . Pooled analysis revealed all cause death to be significantly lower in the cardiologist care group with relative risk (RR) of 0.79, CI 95% [0.73, 0.86], whereas heart failure re-admission was similar in both groups RR 0.87, CI [0.68, 1.11]. Prescription of goal-directed medical therapy was higher in the cardiologist group with statistical significance in beta-blockers RR 1.22, CI [1.03, 1.44] and mineralocorticoid antagonists RR 1.23, CI [1.06, 1.44], but not Angiotensin-converting enzyme inhibitors/ Angiotensin receptor blockers RR 1.08, CI [0.99, 1.18].


Conclusion: This systematic review showed that while heart failure patients managed by cardiologists have higher NYHA functional class and lower ejection fraction, they had improved survival. This may be mediated by higher rates of guideline-directed medical therapy in the cardiologist-care group. However, the two groups had similar rates of HF hospitalizations, readmissions, and emergency department visits. This review emphasizes the importance of cardiologists’ engagement in the care of heart failure patients. When continuous co-management by cardiologists is infeasible, systems should consider intermittent cardiology evaluations (even if through electronic consultations) and pursuing medication optimization programs (e.g. pharmacists-led). More studies are needed to define other components in cardiologists’ care (beyond medical therapy optimization) that contribute to improved clinical outcomes.