Surgically based therapies in heart failure: implications for patients and nursing practice

Heart failure (HF) is a prevalent, costly, and complex condition, estimated to affect 65 million adults worldwide, with predictions suggesting it will continue to grow as populations become older and sicker.1 Despite unquestionable successes with guideline-directed medical therapy in HF with reduced ejection fraction (HFrEF), often referred to as the ‘four pillars’ of care;2 non-elective HF hospitalization and readmission rates have remained unchanged over the past four decades.3 Therefore, the pursuit for effective treatments to improve morbidity, mortality, and quality of life (QoL) outcome for patients continues and the role of invasive procedures must not be forgotten. The most obvious choice is to look for strategies that tackle the most common cause of HF, coronary artery disease (CAD). Until recently, the decision to improve blood supply to viable infarcted parts of the myocardium in those with severe ischaemic cardiomyopathy via revascularization was based on the results of the Surgical Treatment for Ischaemic Heart Failure (STICH) randomized controlled trial (RCT).4 Following lengthy monitoring, STICH showed that 5 years post-coronary artery bypass graft (CABG), patients did not live longer; however, by ∼10 years, survival rates favoured the intervention group over the control group receiving optimal medical therapy (OMT) alone. More recently, the REVIVED-BCIS2 RCT has reignited discussion;5 in this study of 700 medically optimized patients with HFrEF with severe ischaemic cardiomyopathy, percutaneous coronary intervention (PCI) failed to deliver added benefits on all-cause mortality or HF hospitalization, compared with those receiving only OMT. Since the publication of BCIS2, there has been much debate, and some have highlighted that enrolled participants were relatively well (based on low New York Heart Association functional class scores) with little or no angina symptoms, making extrapolation of results to real-world settings difficult.6 To address under-representation of these older and sicker patients in cardiovascular clinical trials,7 the SENIOR-RITA trial8 investigated whether elderly (>75 years) patients presenting acutely with Type 1 non-ST-elevation myocardial infarction benefited from the addition of invasive treatment (PCI or CABG) to OMT. At the end of 4.1 years, the results showed no differences on cardiovascular death between the invasive and conservative (OMT) groups. Lastly, the ORBITA trials9,10 focused on the management of angina symptoms and demonstrated that PCI for stable CAD is only effective in relieving angina if patients are not on optimal anti-anginal medications. Given that hard outcomes appear to be unchanged by invasive procedures, should decision-making shift to QoL and functional improvements? This is a particularly relevant question for older patients, who have voiced that maintenance of cognitive and physical function is more important than life-prolonging treatments.11 Chronic HF patients experience debilitating symptoms that significantly reduce their QoL and contribute to psychological distress.12 Those with CAD may face an even greater symptom burden, as angina exacerbates their already poor QoL.13 For example, younger individuals with HF and ischaemic heart disease, report that the negative impacts of angina are particularly associated with psychosocial stress, ability to work, self-care, and physical activity.14 To achieve optimal management of their condition, healthcare professionals ask HF patients to engage in a series of complicated processes that can lead to more frequent hospital visits or follow-up activities, all of which have the potential to increase the burden of treatment.15 High burden of treatment has been associated with non-adherence to treatment regimes, higher likelihood of disease deterioration, and more frequent episodes of decompensation.15 Furthermore, hospital admissions are associated with unintended consequences, particularly in older adults, such as increased risk of harm, poor healthcare quality (i.e. lower effective patient–healthcare professional communication) and lower QoL.16 Therefore, in the light of new evidence summarized previously, there is an even greater need for careful appraisal of individual’s care preferences and QoL. The management of HF has evolved towards a preventative disease management model that draws upon expertise from the multidisciplinary team and includes various components to optimize health.17 Interventions, whether procedural, pharmacologic, or behavioural, should be patient centred and decision-making should be collaborative.18 The value of a surgical intervention should be considered as one factor within the broader context of each patient’s overall clinical condition. Heart failure specialist nurses (HFSNs), who are very effective at coordinating long-term HF outpatient care,17 are perfectly placed to lead these discussions. They have a fundamental role in reducing HF admissions,19 improving QoL, and demonstrating non-inferiority in initiating and titrating HFrEF medications when compared with cardiologists.20 Many HFSNs will already be actively reframing care to focus on patient’s own narratives and goals, and this approach allows for the assessment of the risks and benefits of treatments, leading to more holistic and tailored evaluation.21 However, to allow all HFSNs to excel at holistic assessment, further support is needed. Coaching patients in shared decision-making has been shown to be difficult to achieve in practice.22 Therefore, research evaluating how to optimally implement best practice is needed. Aligning interventions with a patient’s healthcare needs, preferences, and lived experiences requires time, training, and skills,23 and HFSNs need support to advocate for change in healthcare delivery. Lastly, fragmented healthcare systems, ill-equipped to deal with multimorbidity,24 generally make holistic practice difficult. More work is needed to empower HFSNs to deliver joined-up, effective care. Regardless of the challenges, we have come a long way in HF care with pharmacological, imaging, and electrophysiology advances. Navigating the complexities of HF management requires a personalized approach and shared decision-making, particularly in the light of new evidence. The future of HF care is exciting for academics and practitioners, and HFSNs are at the very core of advancing effective delivery of care, while advocating for patients needs and preferences. Sara Tavares (Conceptualization, Investigation, Writing—original draft, Writing—review & editing), Norma Caples (Investigation, Writing—review & editing), Mairead Lehane (Investigation, Writing—review & editing), Faye Forsyth (Conceptualization, Investigation, Writing—original draft, Writing—review & editing). Not applicable. Not applicable, no new data were used in this editorial.