Heart Failure Care in Madison, WI
An evidence-based guide to diagnosis and treatment
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By J. Michael Frangiskakis, MD, PhD, MBA, FACC
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Board certified cardiologist and former heart failure medical director
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Last reviewed October 2026
Heart Failure Care at Evexeya Health:
Executive Summary
Heart failure is common, serious, and increasingly preventable. Adults who reach age 40 have roughly a one-in-five lifetime risk of developing it. After a first heart failure hospitalization, about one-in-five patients die within a year; about half will die within five years. This guide, written by Dr. J. Michael Frangiskakis, a board-certified cardiologist and former heart failure medical director, explains how heart failure is defined, classified, and treated.
Today heart failure is defined less by a "weak heart" than by a specific heart disorder that causes signs of fluid overload, such as shortness of breath and leg swelling. Clinicians begin classifying heart failure by left ventricular ejection fraction (EF). The categories are reduced EF (HFrEF, ≤40%), mildly reduced EF (HFmrEF, 41–49%), and preserved EF (HFpEF, ≥50%). A fourth category, improved EF (HFimpEF), covers patients whose heart function has recovered. These categories matter because the treatment evidence differs among them. There are at least 50 distinct causes, grouped into 18 broad categories. In Western countries, the most common are coronary artery disease, high blood pressure, and valve disease. Women and different racial and ethnic groups show meaningful differences in risk, heart structure, and outcomes.
The ACC/AHA staging system frames heart failure as a progression:
Stage A: risk factors only.
Stage B: structural changes without symptoms.
Stage C: symptomatic heart failure.
Stage D: advanced disease.
Patients do not move backward from Stage C. Stages B through D carry a risk of sudden death, often without warning. New cases of HFrEF are declining, but HFpEF is rising with an aging population and increasing risk factors such as obesity; overall survival has changed little.
Lifestyle measures apply at every stage: a Mediterranean-style diet, sodium under about 2,000 mg daily, avoiding alcohol, and at least 150 minutes of moderate exercise each week. Before treatment, conditions that mimic heart failure must be ruled out, including coronary disease, kidney disease, obesity, and deconditioning. Reversible causes such as atrial fibrillation, thyroid disease, and valve disease should be identified and treated.
Treatment combines symptom relief with therapy that changes the course of the disease. Loop diuretics relieve congestion, and bumetanide and torsemide are absorbed more predictably than furosemide. For HFrEF, quadruple guideline-directed medical therapy (ARNI, beta-blocker, MRA, and SGLT2 inhibitor) cuts heart failure hospitalizations by more than 60% and improves survival. HFpEF has fewer proven options. SGLT2 inhibitors have the strongest evidence, and MRAs, particularly finerenone, add benefit. Selected HFrEF patients may also benefit from an ICD or CRT device.
For late-stage disease, the guide emphasizes informed choice. That includes understanding code status and having POLST-style conversations, even though Wisconsin has no formal POLST form. It also means recognizing the limits of advance directives and understanding the difference between palliative care, which continues alongside regular care, and hospice.
The central message is that prevention offers the greatest opportunity to change outcomes. Key measures include blood pressure control, weight management, quitting smoking, and the AHA's Life's Essential 8. Evexeya Health provides unhurried, evidence-based cardiology consultation in Madison and Sun Prairie for patients at any stage.
What is Heart Failure?
Historically speaking, the terms “congestive heart failure” or just “heart failure” were used to refer to the condition often associated with how a person who survived a heart attack would develop an enlarged, weakened heart. They may eventually go on and die from excess water in their body, giving them swollen legs and difficulty breathing due to fluid accumulating in and around their lungs. Then, as we neared the end of the 20th century, we began to learn more about how there were other situations where people may present with difficulty breathing, swollen legs, and signs of congestion, but their hearts were not weakened. We then understood that there were different types of heart failure, not just a swollen, weakened heart. Today, heart failure is a general term that refers broadly to a situation where some heart disorder is associated signs and symptoms of fluid overload in the body, such as shortness of breath or swelling in the legs.
Why Care About Heart Failure?
By the time someone reaches forty years of age, there is a one in five chance they will develop heart failure in their lifetime. Once someone is hospitalized with heart failure, there is a one in five chance they will die within the first year after that hospitalization and there is a fifty percent chance they will die within five years of their initial hospitalization. Consequently, it is common for people to develop some form of heart failure and unfortunately heart failure is often not survivable. Given the common nature of heart failure and shortened lifespan once it develops, attention is increasingly being focused on prevention.
How to Describe a “Strong” or “Weak” Heart?
In the clinical setting, we discuss the strength of the heart in terms of ejection fraction (EF), which refers to how much of the blood in the heart is pushed out of the heart to the body with each squeeze. This EF most often refers specifically to the left ventricle as the main pumping chamber, often denoted as LVEF. If sixty percent of the blood in the heart is pushed out with each heartbeat, we say the EF is 60%. In broad terms, we have classically said a normal EF is between 55-70%, calling the 50-55% range low-normal. Women typically have smaller hearts than men. With a smaller heart size, the lower limit of normal is ≥53% in women and ≥52% in men. However, given the limitations of our technologies for assessing heart function, we will often still refer to ≥50% as the lower cutoff for normal heart function. In many settings, it is challenging to see variations <5%, so EF is often reported as 5% ranges, such as EF 55-60%.
What are the Heart Failure Types?
Understanding the strength of a person’s heart when they have heart failure is important, as treatment strategies vary depending on the nature of heart disease. The strength of a person’s heart is one of the most important factors when working to identify the nature of their heart disease. People with an EF ≤40% are considered to have “heart failure with reduced EF” (HFrEF). An older, alternative term for HFrEF is systolic heart failure. People with normal EF, that is EF ≥50%, are typically considered to have “heart failure with preserved EF” (HFpEF). The older, alternative term for HFpEF is diastolic heart failure. Those with an EF 41-49% are often labeled as having “heart failure with mildly reduced EF” (HFmrEF). Historically, clinical trials were often based on EF cut-offs of ≤35% or ≤40%, which complicates comparing different trials and may limit whether a given trial pertains to the patient sitting in the doctor’s office. Unfortunately, the designations become even more complicated than just HFrEF, HFmrEF, and HFpEF. For instance, someone with a normal EF may have previously had an abnormal EF, so they are considered to have “heart failure with improved EF” (HFimpEF). A person with an EF 55% could either have a completely normal function designated as HFpEF or they could have recovered from a weakened heart and would be designated as HFimpEF. While these designations may at first appear confusing, they are important, as they provide guidance as to how best to manage the person’s heart failure.
What Causes Heart Failure?
There are 18 different groups of disorders leading to heart failure (Table 1), with multiple distinct entities within each group. When considering specific types within each group (e.g., aortic valve stenosis and mitral regurgitation are two types of heart valve disorders that can both lead to heart failure), there are at least 50 unique causes of heart failure. In more developed nations, often termed “Western”, the three most common groups of heart failure are heart disease due to blocked heart arteries, high blood pressure, and valve disease. HFrEF is more often associated with diseases of the heart arteries, such as heart attacks. HFpEF is more often associated with high blood pressure and valve disease. In broad terms, HFmrEF tends to behave more like HFrEF, though is less severe and may have better survival.
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Heart artery disease
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High blood pressure
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Heart valve disease
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Arrhythmia-related
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Infiltrative
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Infective
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Inflammatory
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Toxic
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Heritable
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Pericardial disease
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Metabolic disease / nutritional deficiency
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Pregnancy-related
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Stress-induced
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Pulmonary / Right-sided
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Congenital
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High-output mediated
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Other
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Idiopathic
Table 1. Heart failure causes
Gender and Heart Failure
Women have a greater risk of heart failure from high blood pressure, diabetes, and obesity than men. Furthermore, women may have added risk of heart failure if they have experienced pre-eclampsia. Women may have more thickening of their heart muscle walls, more stiffness of their heart muscle, and worse relaxation of their heart muscle. Women are more likely to develop HFpEF than men. Women’s hearts tend to be smaller than men’s, which would typically lead to a higher estimation of heart function. As such, an EF seen as “low-normal” in a woman may actually be mildly reduced in that individual.
Race, Ethnicity, and Heart Failure
Just as there are differences based on gender, race and ethnicity also impact heart failure. Two common measures of heart failure impact are hospitalization and death, particularly given how hospitalizations can predict increased risk of death in the near term. Black patients have higher rates of heart failure hospitalization, though a lower rate of death than White patients. Similarly, Hispanic patients have similar or higher rates of heart failure hospitalization while having similar or lower rates of death than White patients. Asian and Pacific Islanders have similar heart failure hospitalization rates while having lower rates of death than White patients. The observed racial and ethnic differences in outcomes suggest a potential role for evaluating different prevention and treatment strategies by race and ethnicity.
Heart Failure Progression
As I mentioned earlier, “heart failure” historically referred to reduced heart function (HFrEF), but was more recently understood to include congestion with normal heart function (HFpEF). Interestingly, while the rate of new cases, that is heart failure incidence, for HFrEF has gradually been decreasing as prevention, treatment, and technology have been improving, the incidence of HFpEF has been increasing. The increased incidence of HFpEF is thought to relate to factors such as an aging population and rising prevalence of risk factors. For instance, there are increasing numbers of people living with obesity, a risk factor for heart failure. Consequently, the overall number of people living with heart failure at any given time, the prevalence, has been increasing. Despite advances in managing heart failure, overall heart failure mortality rates remain relatively unchanged. As we’ll see later, the lack of improvement in heart failure survival may be driven by limited treatment options being available for those with HFpEF.
With limited success in improving heart failure survival, increased attention has been focused on prevention and understanding the factors leading to heart failure. To this end, cardiology societies have developed a staging system to help depict the progression to developing heart failure, as shown in Figure 1.
Figure 1. Heart failure progression
Stage A
A person is in Stage A when they are at risk of heart failure but lack any current or prior symptoms of heart failure and have no objective evidence of heart failure, such as structural heart changes seen on an echocardiogram or abnormal bloodwork. These people may have high blood pressure, coronary artery disease, diabetes, obesity, congenital heart disease, a family history of cardiomyopathy, or have been exposed to cardiotoxins. It is important to note that Stage A risk factors are influenced by poverty, education, and social disparities.
Stage B
A person is in Stage B when, even though they don’t have symptoms, their cardiovascular system has started to change. The changes may take the form of thickening heart muscle, enlarging and/or weakening heart chambers, or worsening valve structure and/or function. There may also be evidence of damage or strain evident from bloodwork.
Stage C
A person enters Stage C when they develop symptoms of heart failure and their cardiovascular system has developed changes mentioned in Stage B above. Importantly, once someone enters Stage C, they do not return to Stage B even if their symptoms resolve. If their EF had been ≤40% and becomes >40% on follow-up, they are considered to have HFimpEF and not HFmrEF or HFpEF, as they are still felt to be at risk of returning to HFrEF and may need to be treated differently than those with HFpEF. There is overlap between HFimpEF and HFmrEF, as we may not know how low a person’s EF had been at its worst. Remission and Recovery are newer terms that have not been widely adopted. A person may enter remission with normalization of heart function and bloodwork biomarkers, though a complete recovery is rare and a person is likely to remain at risk for the remainder of their lives once they enter Stage C.
Stage D
A person enters Stage D when they have severe signs or symptoms of heart failure with light activity or at rest. The person may have recurrent hospitalizations despite being on optimal medical therapy, may be intolerant to the medical therapy, and may require advanced medical or mechanical support in the hospital. Ultimately, they may progress to heart transplant or transition to palliative care and hospice.
An important point noted in Figure 1 is that people in Stages B, C, and D are all at risk of sudden death due to factors related to the changes in the cardiovascular systems. Unfortunately, these episodes of sudden death may not have any warning signs. The risk of sudden death and a spiral with limited control is why it is vital to focus on prevention in Stage A.
Stage 0 (not shown)
A person is in Stage 0 when they have no evidence of any symptoms and have none of the risk factors associated with heart failure.
Alternative Heart Functional Classification
Instead of classifying heart failure by Stage A/B/C/D, an older, alternative way to classify the different severities of heart failure is called the New York Heart Association (NYHA) Functional Classification, shown in Table 2. Historically, clinical trials were used during enrollment of patients to guide treatment based on comparable levels of symptoms and disease severity. For example, patients classified as being NYHA IV may have been excluded from trials designed to treat milder disease, because patients in NYHA IV may have had irreparable damage to their bodies and may not show benefits from new treatments. Once patients reach Stage C, they generally are classified into classes NYHA II-IV.
Table 2. NYHA Functional Classification
Decompensated vs. Worsening Heart Failure
A person may be doing well and have a sudden clinical change requiring medication change, such as hospitalization for additional fluid removal, or diuresis, after a holiday dinner party, a bout of atrial fibrillation, or a seasonal cold. If, once these individuals receive appropriate treatment, they return to their prior functional classification level and the assessment of their cardiovascular system returns to pre-episode levels, they are considered to have had an episode of decompensated heart failure. Alternatively, should the episode result in worsening functional status and/or cardiovascular status, they are felt to have worsening heart failure, not decompensated heart failure. Again, the role of appropriately classifying patients is in the hope that appropriate classification improves diagnostic strategies and/or treatment planning.
What Can a Person Do?
By this point, it is clear there are different ways to classify heart failure, but what does that mean for the individual? What are they to do? Some ideas are the same, whether they are in Stage 0, A, B, or C. A heart healthy diet and lifestyle are crucial, as they may help prevent the risk factors in Stage A, slow the progression in Stage B, or avoid decompensation in Stage C.
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The Mediterranean diet with reduced saturated fat is one of the most widely studied diets and helps prevent high blood pressure, diabetes, and cardiovascular disease. The American Heart Association provides guidance on the Mediterranean Diet here.
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Avoiding excess sodium and keeping daily sodium roughly less than 2,000 milligrams per day, including what is in food, is crucial to both avoiding high blood pressure and avoiding episodes of decompensation. The American Heart Association provides multiple pages talking about sodium and salt, with this page and this page both being good starting points.
An important side note is that some guidelines refer to “sodium” and others refer to “salt” when giving amounts. Common table salt is sodium plus chloride, with sodium making up 39% of the mass of sodium chloride. So, if the European guidelines indicate keeping salt less than 5 grams per day, that is roughly the same as an American guideline indicating sodium should be less than 2 grams per day or less than 2,000 mg per day.
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Alcohol in any form is toxic to the heart and is associated with a variety of risk factors in Stage A. Also, given alcohol is a cardiotoxin, those with EF <50% are particularly at risk of worsening heart function if they continue to drink and should consider abstaining from alcohol consumption. Again, there is no “healthy” or “safe” amount of alcohol. Old suggestions of benefit from red wine due to resveratrol have been disproven.
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Regular exercise, at least 150 minutes per week of moderate cardiovascular exercise, can both help prevent progression of cardiovascular disease and can also improve the quality of life in those with heart failure. Even in Stage D, NYHA IV heart failure, everyone benefits from some level of activity, though those in later stages of heart failure need close supervision and guidance from their physician.
Heart Failure Mimics
Before labeling a person with certain signs and/or symptoms as having heart failure, it is vital to exclude mimics, as there are other conditions which can lead to the same signs and/or symptoms. Common examples include coronary artery disease, chronic kidney disease, pregnancy, obesity, and deconditioning. As such, once someone develops concerning findings, they will need a thorough evaluation to ensure they receive appropriate care.
How Can A Cardiologist Help?
A cardiologist will help in two main ways once a person is diagnosed with heart failure. First, the cardiologist will work with the patient to identify and treat the reversible causes of heart failure. Examples of reversible causes of heart failure include atrial fibrillation, thyroid disorders, and valve disease. Second, the cardiologist will work with the patient to ensure they are on the most appropriate medications given their clinical situation.
Coronary Artery Disease
Because coronary atherosclerosis or artery disease can both be a mimic of heart failure as well as cause heart failure, an early step in both addressing symptoms as well as managing heart failure will be an assessment of the arteries of the patient’s heart. For some patients, they may go through a stress test and for others, they may go through a specialized CT scan to look at the arteries of the heart. Either way, an evaluation of the blood flow of a person’s heart is important. It is worth noting that we have no data that treating coronary obstructions with stenting improves outcomes in HFrEF or HFpEF, though those with HFrEF do have a long-term mortality benefit if they go through open chest surgery for coronary artery bypass grafting.
Valve Abnormalities
Once a person develops a valve condition that is severe enough to contribute to heart failure, it’s possible that fixing the valve may not allow a person’s heart to fully recover. Addressing some valve issues, such as severe aortic valve stenosis or severe mitral regurgitation can substantially improve a person’s survival, rate of hospitalization, and quality of life. As such, monitoring for worsening valve issues is an important part of prevention in Stage A, paying particular attention to addressing the valve disorder before heart failure develops.
Atrial Arrhythmia
There are a variety of electrical issues in the heart that can lead to heart failure. One of the more common issues that leads to and/or worsens heart failure is atrial fibrillation. Atrial fibrillation is an electrical disorder where the regular heartbeat is replaced with an erratic, often rapid heartbeat and is associated with heart failure and stroke. Of a primary concern with atrial fibrillation is that the rapid, irregular rhythm in the atria can lead to the ventricles going far faster than is normal. A normal heart rate range is often cited as being 60-100 beats per minute (bpm), though certainly some will have lower and higher rates depending on factors such as fitness and activity levels. In atrial fibrillation, the top of the heart has rates of 300-400 bpm, though most are blocked by the atrioventricular (AV) node between the atria and ventricles. Because of the AV node, the bottom of the heart may only beat at 75-100 bpm in atrial fibrillation. However, at times the AV node can’t block as much and ventricular rates may rise to 150-200 bpm. If the heart runs well above 110 bpm for too long, the person is at increased risk of developing HFrEF. As such, prevention and treatment of heart failure in the setting of atrial fibrillation is heavily focused on avoiding prolonged episodes of high heart rates. For a small group of patients, there may be a role of trying to avoid atrial fibrillation altogether through medicines and procedures, though this is less common.
Decongestion With Diuretics
Importantly, some medications are used to help the patient feel better, while others are used to try to stabilize and potentially even improve a person’s heart function. For example, if someone is short of breath due to excess water in their body, they may be given a diuretic, which is a medicine that removes excess water from their body by increasing urination. While not all diuretics remove substantial amounts of water from the body through markedly increased urination, some diuretics are particularly efficient at promoting excess liquid removal and are known as loop diuretics, referring to where they act in the kidneys.
Loop diuretics include furosemide, bumetanide, and torsemide. All are generic and quite affordable. Furosemide is the oldest of the three and the least refined, with bumetanide and torsemide having more favorable biology due to improved, far more predictable uptake into the body known as bioavailability. The bioavailability issue becomes particularly important when a patient with heart failure has an episode where they develop decompensated or worsening heart failure. In those settings, furosemide bioavailability goes down substantially, requiring a person to take 2-3x their regular dose to ensure they get adequate drug into their system. Bumetanide and torsemide do not have the same failing of unpredictable bioavailability seen with furosemide. Hence, bumetanide can be seen as a superior option for chronic diuretic use. Torsemide may have more limited availability and may not translate as well to hospitalization given some clinicians are not used to working with torsemide. Note, a common conversion factor is that 40mg oral furosemide equates to 20mg oral torsemide which equates to 1mg oral bumetanide.
If the loop diuretic proves ineffective, your doctor may add a different type of diuretic known as a thiazide diuretic. These, by themselves, perform very poorly at removing water from your body and are more often used in routine high blood pressure management. However, when combined with loop diuretics, the thiazide diuretics can “supercharge” the fluid removal. The more aggressive fluid removal comes with risks of kidney damage and significant electrolyte abnormalities, so this option may not be used as often and requires close supervision by your doctor with frequent blood draws to monitor kidney function and electrolytes such as sodium, potassium, and magnesium.
WARNING!!!
A very common area of confusion among those with heart failure is that they may be told their sodium level in their blood is low (Na < 135 mEq/L) and this will get interpreted to mean that the person needs to take in additional salt in the diet. This could not be further from the truth. It is very rare that someone needs added salt. There are rare circumstances where we will use hypertonic saline infusion in the hospital to aggressively remove water, but this is an exception.
While there are rare exceptions, the majority of cases of low serum sodium in the setting of leg swelling and overall congestion relates to normal or even excess sodium in the body combined with excess water. Coffee may have all the coffee grounds it needs, but is very dilute if too much water is added.
Guideline Directed Medical Therapy (GDMT)
In general terms, diuretics do not fix heart problems, but they can help patients feel better. Decades of clinical trials have been conducted to help identify those medicines which are helpful and which are harmful. Our medical society guidelines have generated a highly-informed grouping of preferred medicines to treat heart failure referred to as GDMT. While certainly every person is an individual and care cannot be blindly applied without considering the individual, the GDMT represents a validated starting point in treatment.
When applying GDMT, it is important to understand that the bulk of improvements in reduced hospitalizations and survival have been seen in patients with HFrEF, as the majority of medicines useful in improving outcomes in HFrEF have not proven useful in HFpEF. In HFrEF, successful medicine classes have allowed the heart to heal by decreasing how much work the heart must do and by decreasing signaling to the heart that has been harmful, such as signaling from the kidneys. The four main classes of medicines that have proven beneficial in HFrEF are shown in Table 3. The Number Needed to Treat (NNT) data shown in Table 3 is provided to depict how effective the medicines are at preventing heart failure death, with lower NNT being better. NNT refers to the idea of how many patients need to take a medicine to improve an outcome. For a comparison, we use statins for treating cholesterol widely, though the comparable 3-year mortality prevention NNT’s for statins may be in the 200-400 range. Note that the bulk of data supporting statin use comes from preventing events, such as heart attacks, and are not as focused on mortality. Using one medicine from each class in Table 3 may be referred to as Quadruple Therapy for HFrEF and has been shown to lower heart failure hospitalization by over 60%.
Table 3. HFrEF Quadruple Therapy
The options for treating HFpEF are improving, though there are fewer guideline-supported options available for those HFpEF than for those with HFrEF. The SGLT2i class has shown primarily improvement in hospitalization in patients with HFpEF. The MRA class has shown promising data, though the results are less clear due to trial issues more than the medicines themselves. There are three MRA’s used in heart failure and they are spironolactone, eplerenone, and finerenone. Finerenone is the newest and is a nonsteroidal MRA showing improvement in heart failure events in patients with HFpEF, though its cost may be prohibitive. Spironolactone, a steroidal MRA like eplerenone, is seen as a reasonable alternative to finerenone though it has less convincing data of benefit. Lastly, there are limited roles for the use of BB, ACEi, or ARNI with HFpEF.
Figure 2. ICD Cartoon
Implantable Cardioverter-Defibrillator (ICD) & Cardiac Resynchronization Therapy (CRT)
There are situations, particularly in HFrEF, where the electrical activity may be so defective that the abnormal electrical activity may lead to a worsening heart failure and/or premature death. Early in heart failure management, ICDs were used for a variety of subtypes of heart failure, with a cartoon of an ICD and the wires to the heart in Figure 2. Over time, we learned that the primary benefit of ICDs was in those with longstanding HFrEF, because those individuals were prone to sudden cardiac death due to severe arrhythmias. Alternatively, some people with HFrEF may struggle due to the electrical activity timing in the right and left ventricle were no longer coordinated and the right ventricle triggered well before the left ventricle, such that the right ventricle was trying to push blood into a left ventricle that was still full of blood and hadn’t emptied yet. CRT devices do a reasonable job of restoring synchronization between the chambers, though use of CRT is restricted to small patient population and, even when properly selected, some patients are not able to be synchronized as the appropriate lead cannot be placed where it needs to be placed in their heart.
Late-Stage Heart Failure
Whether a person has HFrEF or HFpEF, there will likely come a time when routine management, such as hospitalization with additional diuretic use proves inadequate and the episode of heart failure threatens the person’s life. Getting to Stage D, NYHA IV heart failure raises important issues and questions. For some patients, they may have already struggled with a variety of health issues such as breast cancer, chemotherapy, and then developing heart failure from the chemotherapy, such that they have fought for so long they are fatigued and no longer have the energy to continue fighting for survival. For others, their heart failure experience can be completely different, such as a woman who developed heart failure later in life due to valve disease and is otherwise relatively well. Some may have so many other health issues that they are simply worn out, while others appear to be only struggling with their one, albeit severe, heart issue. At this stage, some opt to stop trying to fix their condition and focus on comfort, known as palliative care and/or hospice care. Others opt to have discussions about mechanical assist devices known as left ventricular assist devices (LVADs) or heart transplantation. LVADs and heart transplantation may be options for a very small minority of patients and are outside the scope of care for most patients. Getting to late-stage or end-stage heart failure brings up important discussions regarding quantity of life (i.e., how long a person’s body is alive) versus quality of life (i.e., how long a person can meaningfully participate in, and enjoy, life).
Code Status
Central to later stage heart failure management is understanding the patient’s wishes for how they see their end of life care and how they wish to die. Too often patients are unaware that they have choices in their care, often feeling that they are on a runaway train and they can’t influence the process. In the early stages of heart failure, patients may present to the emergency department scared, feeling they may be dying, and are looking for help. The system is well-designed for this situation, as the health systems are geared to identifying and treating these emergent situations. However, when it’s the sixth or tenth hospitalization for heart failure, the patient is experienced and has a much better sense of what is happening, possibly even dreading the next steps but not knowing what their options are in their care.
If a patient no longer wants to go through chest compressions, also known as cardiopulmonary resuscitation (CPR), if their heart stops and they want to die naturally, all they have to do is tell their doctor. This is then placed on the patient’s chart as a code status of Do Not Resuscitate (DNR). In some settings, it may be indicated by Allow Natural Death (AND). I would encourage people opting to be DNR to consider wearing a medical alert bracelet indicating their desire to have their code status as DNR. I have seen too many people who had elected DNR status who collapsed away from friends and family, were put through the entire resuscitation process by bystanders who meant well, only to have friends or family arrive at the hospital indicating the person had wished for DNR status and the person is now clinging to life on a ventilator. From years of experience, it is a much more challenging decision to decide to withdraw care and stop the ventilator than it is to decide not to use the ventilator and perform CPR in the first place.
Physician Orders for Life-Sustaining Treatment (POLST)
For some who want to provide more details around the dying process, there is the POLST document which allows a patient to discuss more of the details of the patient’s wishes at end of life with their doctor. The POLST document includes a discussion about CPR and DNR status, but it also includes discussions about the general goals of treatment and nutrition at end of life. For some people, they may want the doctor to try to fix any readily reversible issues at the end of life, but should no obvious issue be identified they want to be allowed to die naturally and not artificially and unnecessarily extend their lives. It is only natural for friends and family to focus on a person stopping eating days before dying, but at the end of life, food often becomes irrelevant for the patient. Importantly, not all states have adopted a formal POLST form for the medical record. Wisconsin does not have a formal POLST form, even though La Crosse, WI, was a founding site in the POLST movement. Nonetheless, a POLST form ( https://polst.org/ ) can serve as a good source of information to guide the discussion between a patient and their doctor. Even if the POLST form is not valid in Wisconsin, your physician, as well as your family, will appreciate that you were able to participate in the difficult decisions at a time when you were able to have a thoughtful discussion about a challenging issue.
Advanced Directives
An advanced directive is a legal document, but has little to no role in the hospital in the acute setting, as it provides little clinical guidance to the patient’s wishes. I have had numerous encounters with family members bringing in their loved one’s advance directive, hoping it would provide guidance in end of life circumstances, only to realize how little information of use is contained in an advanced directive. Yes, it is useful to designate medical power of attorney, but advanced directives are often written with such flexible terminology as to be of little use in emergent settings. Rarely do they accurately contain enough details to help guide important end of life decisions, so friends and family are left guessing what the patient would want in their final days. DO NOT rely on the advanced directive to convey your end of life wishes, as it is laden with opinion terms. What one doctor may see as being a terminal condition, another may see another opportunity for trying yet another treatment option with only the faintest hope of success.
Palliative Care
Too often in my career I have seen people get to late-stage heart failure unaware of their options. Some may not know they are able to tell their doctors they want to stop all the invasive procedures. Some may confuse palliative care and think it is the same thing as hospice and think that choosing to engage palliative care means people will stop trying to help them live. This sense of giving up couldn’t be further from the truth. Palliative care refers to care people receive when the person has a condition that may lead to the person’s death in the next few years or so. Receiving palliative care allows patients and their families to talk openly about death and the process of dying, as we frequently don’t talk about the dying process. It certainly is understandable that people don’t want to talk about death, as the entire issue is scary. When someone is talking to palliative care doctors, in addition to their own cardiologist and primary care doctor, the person can live their life and get all of the regular care they are used to receiving. Signing up for palliative care does not mean all other care stops. Engaging palliative care allows for a smooth, planned transition to the end of life, particularly allowing for the patient’s family to be engaged and understand their role in the dying process.
Hospice
Hospice represents an alternative option for patients with end-stage heart failure as well as many other end stage diseases. There are patients who are worn out, are tired of hospitalization and the associated procedures, and are ready to die. When someone enters hospice care, this typically is with the idea that they have six months or less to live. However, I have seen people enrolled in hospice who actually lived longer than six months, though this is uncommon. Official hospice programs are structured such that once someone enters hospice, most other care stops and care is entirely directed at comfort and symptom management. People are typically able to eat and drink what they want, often with previously restricted diets removed if appropriate. Medicines we routinely administer to treat long term issues, such as cholesterol, are stopped. The doctor managing hospice generally takes over and decides if any medicines the patient had been taking chronically are useful at the end of life, but most are stopped. The hospice doctor then makes available a few other medicines to ensure the patient is comfortable, particularly focusing on pain and anxiety control. When a person gets to the end of life, doctors need to do all we can to ensure a patient dies with comfort and dignity. Once a patient enters hospice, there can be a sense of calm and peace as people realize they are no longer fighting and struggling, but instead can focus on enjoying as much as they can from their remaining days.
Closing Thoughts
We have come a long way in managing heart failure, particularly HFrEF. We have seen a number of improvements and identified a variety of new treatments to help people with heart failure live longer and more comfortable lives. Despite the many improvements, the dominant idea must be that the focus needs to be on early prevention and management of risk factors, as for many people we have few options to impact care once they get to later stage heart failure. Prevention needs to focus on managing blood pressure, avoiding obesity, stopping smoking, and the other measures to prevent heart disease, as details in the American Heart Association’s Life’s Essential 8.
References
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About Dr. Mike
Dr. J. Michael Frangiskakis, MD, PhD, MBA, FACC
Adult Cardiologist in Madison, WI
Dr. Mike has nearly 20 years of experience practicing as an adult non-invasive cardiologist. He is board certified in internal medicine, general cardiology, echocardiography, nuclear cardiology, and advanced cholesterol management. Dr. Mike has particular interests in cardiovascular disease prevention, heart failure management, and arrhythmia management.
Dr. Mike believes in a personalized approach to patient care, taking as much time as is needed for each patient, particularly given needing to see a cardiologist can be a stressful experience. That means new patient office visits are often in the realm of 60-90 minutes, with all of that time spent with their own heart doctor, Dr. Mike. It is essential to focus on learning what prevention elements can be built into a person's life to avoid disease and not simply focus on the treatment of disease once it develops. Using tools such as Evexeya's WholeHeart Wellness & Prevention lab profiles, Dr. Mike is better able to help his patients understand their individual risks and where to focus their preventive efforts. Dr. Mike understands that every patient is different and has unique preferences, so his goal is to help you be the best You are not simply forced into being a standardized patient from guidelines. That said, Dr. Mike monitors guidelines to help inform care and maintain quality in his cardiology clinic.
As a direct specialty care cardiologist, Dr. Mike strives to see patients within 1 week of a new appointment being made, though usually within 1-2 days depending on patient availability. Clinic hours are typically 9am - 5pm, though flexible early morning or evening hours may be available on request. Telehealth visits and secure messaging are available to existing patients. Improved after-hours access is available to those subscribing to Dr. Mike's Premium Plan membership.
Dr. Mike has access to the local health system's electronic medical systems and can readily review the Epic charts of patients. This allows for seamless collaboration and maintaining continuity of care. Dr. Mike also readily communicates with primary care providers, whether they are part of a large health system or are practicing independently, ensuring bidirectional communication for continuity of care. While Dr. Mike is not able to provide emergency care, he will be able to review records from emergency department visits and hospitalizations.
Your business deserves a 10 star review [out of 5 stars].
I can truly say that with Dr. Mike I feel confident walking with him as a partner to my long-term health and goals - far beyond just a quick doctor visit.
I visited Dr. Mike's clinic, and I loved it. His attention and professionalism with his patients is exceptional, both in how he speaks to you and in how he explains the detailed information about your case.