Growing Calls to Marry HF Specialists With Cardiac Critical Care

NATIONAL HARBOR, Md. — With the needs of advanced heart failure (HF) dwarfing the supply of skilled physicians, HF specialists and others are well-positioned to prove their value in the contemporary cardiac ICU (CICU) — and the clock is ticking for training and accreditation to keep up.

The problem for the workforce is that CICU patients are increasingly complex and affected by HF. More and more people are entering CICUs with congestive HF and cardiogenic shock, accompanied by comorbid sepsis and liver failure and an increasing need for non-cardiac procedures such as bronchoscopy, mechanical ventilation, and renal replacement therapy.

“CICUs are becoming the HF unit whether people want to acknowledge it or not,” said Jason Katz, MD, MHS, co-director of the CICU and MCS program at Duke University in Durham, North Carolina, during a discussion at the Heart Failure Society of America (HFSA) annual meeting.

Problems meeting the uniquely resource-intensive care needs of patients with advanced HF and mechanical circulatory support are exacerbated lately by pandemic-related staffing issues, according to Ann Gage, MD, director of the CICU at Centennial Medical Center in Nashville.

As there just aren’t enough dual-boarded critical care cardiologists — or critical care doctors in general, for that matter — the hope is that advanced HF-trained cardiologists might help fill the talent gap in the CICU if they learn to manage critically ill patients during training.

Katz noted that he is dual boarded-certified in advanced HF and critical care. He contrast the fewer than 50 training spots each year for critical care cardiologists with the over 80 programs training one to five HF cardiologists ever year.

There are incentives for HF specialists to make the jump: during this period of dwindling appeal and job uncertainty in advanced HF as a career — the “elephant in the room” — HF doctors should strengthen their niche in critical care, suggested Rachna Kataria, MD, of Rhode Island Hospital and Brown University in Providence. Kataria is a recent advanced HF transplant cardiology (AHFTC) fellowship graduate.

“We need to rebrand ourselves…We’re not just [ventricular assist device] and transplant physicians,” said Kataria. “Critical care training should be a core competency at this point.”

She said that HF fellows should get more clinical training in areas such as post-cardiac surgery management, mixed shock and neurologic emergencies, and palliative care. They should also enrich skills in intubation, bronchoscopy, airway and ventilator management, and anesthesia during their training, she added.

Ultimately, it will take leadership to implement safety initiatives and quality improvement studies to show that HF cardiologists are not a liability in critical care, but that they bring value to patients, according to Kataria.

Katz noted that the specific components in each program will need to be tailored to fit the institution’s needs and demands.

He cited a proposed pathway in which interested trainees pass through internal medicine residency and general cardiology fellowship before reaching AHFTC fellowship embedding cardiac critical care. At the end, they can be board-certified in cardiology and AHFTC with a distinction in cardiac critical care, he said.

He acknowledged the barriers to getting doctors interested in the AHFTC-cardiac care fellowship — training fatigue, relocation, and having fellows waiting another year before they can start paying off their student loans.

As such, some believe there is room for more nurse practitioners and physician assistants to step into the CICU team. These providers currently have few options for advanced HF-specific training, yet structures are being put in place to encourage them down this path.

The Mayo Clinic Arizona in Scottsdale has a 1-year physician assistant fellowship for advanced HF, which could serve as a model for future efforts, for instance. And the HFSA is also launching a HF certification specifically for advanced practice providers in the next few months, according to Shannon Cornell, A-NP, of Medical University of South Carolina in Charleston.

For now, Katz urged stakeholders to engage professional societies like the American College of Cardiology to develop new training pathways and determine what is necessary for the future of cardiac critical care.

“Until that time, it’s the Wild Wild West,” he said. “We’re flying by the seat of our pants.”