Discordant Perceptions of Prognosis and Treatment Options Between Physicians and Patients With Advanced Heart Failure

Abstract

Objectives: This study assessed patient and physician perceptions of heart failure (HF) disease severity and treatment options.

Background: The prognosis for ambulatory patients with advanced HF on medical therapy is uncertain, yet has important implications for decision making regarding transplantation and left ventricular assist device (LVAD) placement.

Methods: Ambulatory patients with advanced HF (New York Heart Association functional class III to IV, Interagency Registry for Mechanically Assisted Circulatory Support profiles 4 to 7) on optimized medical therapy were enrolled across 11 centers. At baseline, treating cardiologists rated patients for perceived risk for transplant, LVAD, or death in the upcoming year. Patients were also surveyed about their own perceptions of life expectancy and willingness to undergo various interventions.

Results: At enrollment, physicians regarded 111 of 161 patients (69%) of the total cohort to be at high risk for transplant, LVAD, or death, whereas only 23 patients (14%) felt they were at high risk. After a mean follow-up of 13 months, 61 patients (38%) experienced an endpoint of 33 deaths (21%), 13 transplants (8%), and 15 LVAD implants (9%). There was poor discrimination between risk prediction among both patients and physicians. Among physician-identified high-risk patients, 77% described willingness to consider LVAD, but 63% indicated that they would decline 1 or more other simpler forms of life-sustaining therapy such as ventilation, dialysis, or a feeding tube.

Conclusions: Among patients with advanced HF, physicians identified most to be at high risk for transplantation, LVAD, or death, whereas few patients recognized themselves to be at high risk. Patients expressed inconsistent attitudes toward lifesaving treatments, possibly indicating poor understanding of these therapies. Educational interventions regarding disease severity and treatment options should be introduced prior to the need for advanced therapies such as intravenous inotropic therapy, transplantation, or LVAD.

Keywords: advanced heart failure; cardiac transplantation; mechanical circulatory support; patient decision making; ventricular assist device.

Figure 1

Interim events after a mean follow up of 13±9 months among MedaMACS patients stratified by physician and patient perceptions of risk for progression of heart failure.

Figure 2

Kaplan-Meier Survival by Initial Perceptions of Heart Failure Prognosis. The High Risk cohort included patients that physicians and patients both perceived as high risk while the Low Risk cohort included patients that physicians and patients both perceived as low risk. Patients were censored at time of transplant or ventricular assist device placement.

Figure 3

Kaplan-Meier Freedom from VAD, Transplant, or Death by Initial Perceptions of Heart Failure Prognosis. The High Risk cohort included patients that physicians and patients both perceived as high risk while the Low Risk cohort included patients that physicians and patients both perceived as low risk.