–A Conversation About Heart Failure With Milton Packer And Richard Lehman (Part 2)
This is the second installment of an ongoing discussion about heart failure between Milton Packer, who has been leading major heart failure clinical trials for decades, and Richard Lehman, a retired UK GP who writes a blog for the BMJ website. (Click here to read the first installment of this series.)
In this episode I asked Richard Lehman to respond more fully to this statement made by Packer:
“In truth, no patient with chronic heart failure is stable; they all have a progressive disease that requires aggressive treatment.”
Richard Lehman:
As with most of what Milton has said so far, I am in broad agreement, and greatly value his positive approach. The potential for instability is always there in chronic heart failure, and clinicians should always be on the lookout for treatable causes, since every episode of decompensation has a reason. Unfortunately, attempts to predict these episodes have been largely unsuccessful– telemonitoring, daily weighing, measuring B-type natriuretic peptide and so on. I hope Milton agrees that we should not make the lives of patients more burdensome by intensive monitoring unless we have good evidence that it helps towards some goal – e.g. prolongation of life, avoidance of hospital admission – which we know truly matters to them.
Richard Lehman
Working in British primary care for over 35 years, I am seeing heart failure from a perspective that differs in three ways from Milton’s. First of all there are the cultural differences between US and UK medicine, including the way we use words. “Aggressive” always carries a bad meaning for British patients. “Intensive” or “thorough” would work better over here. But that’s a minor point. Secondly, our patients in general practice rarely move doctors, so we see them right through their lives, look after all their conditions, coordinate their care, and explain the process as we go along. So in many cases the management of their heart failure may not be the only factor in their medical management, and there may also be non-medical factors which influence our management. Thirdly, the epidemiology of heart failure in UK primary care suggests a different pattern from the one Milton describes. The latest paper came last month from some Oxford colleagues.
This study does not determine the mean age at diagnosis for heart failure in the UK, but the investigators confirm that it remains at 76. And the analysis does not distinguish between HF with or without reduced ejection fraction, though the latter diagnosis is only grudgingly accepted by most UK physicians, and the THIN database used here would heavily favour an echocardiographic diagnosis of HF with reduced systolic ejection fraction. Of note is that the prognosis of HF in the UK has not improved over the 15 years studied, despite the widespread introduction of HF prescribing incentive schemes, heart failure clinics and community services.
I will stop at this point. I would be very interested to hear how Milton views this: whether the US situation is different, and in what ways we might look to make services more effective.
Milton Packer:
It is amazing how much Richard and I agree. Let me count the ways!
I absolutely agree that we should not make the lives of patients more burdensome by intensive monitoring. I do not believe in telemonitoring or repeated measurement of B-type natriuretic peptide; they are not useful.
I also agree that every episode of decompensation has a reason, but the reason is not generally the occurrence of a new event; it is simply progression of the underlying disease. Consider the analogy between heavy snow accumulating on a mountain-side and the progression of left ventricular dysfunction. Eventually, there is sufficient stress that there is an avalanche. To an outside observer, both appear to be acute events, but in both cases, there is typically no new precipitating cause (other than one additional snowflake or myocyte!). If we are going to prevent events that matter to patients (death and hospitalization), we need to focus on slowing the progression of the underlying illness. There is no other rational approach.
Milton Packer
I also agree that Richard’s experience is totally different than mine. He kindly postulates that there may be cultural reasons, based perhaps on geography or perhaps on the differences between primary and tertiary care. I do not think so. I also do not believe that age is an explanatory factor. Is there an identifiable age at which time I would not care about living and living comfortably? I hope not. Yet, there is a critical difference between the patients who seek help from Richard and those who seek help from me. Richard’s patients have looked to him for help all of their lives, and he provides critical levels of comfort on multiple different levels. The patients who seek my help are not primarily seeking that kind of support (not that I fail to provide it!). Instead, they come to me (after having seen many other physicians before me) because they are desperately tired of suffering and extremely afraid of dying. They ask me: what is the best that medicine can offer? I tell them there is a good path forward, but it is complicated and difficult; yet, if both the patient and the physician are committed, there is so much we can do.
So I think that there is a simple explanation for why my experiences and Richard’s are so different. We both give our patients what they are seeking and value. It is just that the patients he sees and the patients I see have markedly different expectations. That is perfectly OK. That is why both Richard and I exist; we both provide hope, comfort and a path forward. Neither of us is in a position to tell patients what they should value; but we do need to respond very positively to why patients have come to see us.
Great article!