Patient Involvement in Advanced HF Treatment, with Ashley Malliett, DMSc, MPAS, PA-C


Malliett discusses the signs that a caregiver should refer to an HF specialist for advanced care options, including LVAD and heart transplant.

An estimated 600,000-plus Americans are living with advanced heart failure (HF)—a progression of the cardiovascular condition that result in conventional therapy failure. There is no cure, and few clinical strategies that can curb or delay the progression of HF and its symptoms at the advanced stage.

The conversation at the point of advanced HF—between clinicians internally, and with the patient themselves—is critical to ensure care is optimized to what the patient may hope to achieve at that stage.

In an interview with HCPLive during the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, Ashley Malliett, DMSc, MPAS, PA-C, assistant professor and clinical coordinator at the Michigan State University PA Medicine Program, discussed her session presentation on care at the advanced HF stage including left ventricular assist device (LVAD) or heart transplant. A core issue is that the clinician-patient conversation around the realities of advanced HF is often delayed until the diagnosis is actually made—not earlier into the management of standard HF.

“That discussion needs to happen earlier than it's happening right now in the United States,” Malliett said. “So unfortunately, we as advanced heart failure providers typically get referrals too late in the game. We have a window of time; you want somebody to be sick enough to where the benefit of what you are going to offer them is far outweighed by the risks that are there, but not too far outside of a window where the rest of the organs are affected, or it's just the heart is not salvageable.”

Malliett cited the American College of Cardiology (ACC) and American Heart Association’s (AHA) I-NEED-HELP acronym as a 10-item guide for signs to refer a patient to an advanced HF specialist:

  • Intravenous inotropes
  • New York Heart Association (NYHA) class IIIB/IV or persistently elevated natriuretic peptides
  • End-organ dysfunction
  • Ejection Fraction ≤35%
  • Defibrillator shocks
  • Hospitalizations >1
  • Edema despite escalating diuretics
  • Low systolic BP ≤90, high heart rate
  • Prognostic medication; progressive intolerance or down-titration of guideline-directed medical therapy

Malliett explained the necessity of adhering to some of these markers of advancing HF, noting that it may be “too late in the game” if recourse like removing guideline-directed therapy is occurring. Unfortunately, she and her colleagues also face a misperception that HF specialists will “steal away” worsening patients—removing primary care or a more familiar caregiver from the equation altogether.

“No, we want to collaborate,” Malliett said. “There's lots of shared care that can happen. So, if we can establish care early, we can start following a patient early along with their normal provider. And then when that time comes where they need to pull the trigger, so to speak, and get the treatments we have to offer, we already have established care.”

Another reason for timely initiated collaboration between caregivers and specialists would be to ensure a smooth facilitation to high-demand centers. Malliett noted that in her practice in rural Michigan, she is referring patients to 1 of 3 transplant and LVAD-capable centers throughout the entire state—a trend that’s consistent across the US.

“On the advanced heart failure side, we have reached out to our local cardiologists, and even a rural cardiologist, and we have relationships,” Malliett suggested. “We will go do a shared care clinic at their location. The patient can come to their office, and we will go to that office to see that patient.”

Care teams could also involve family practice and internal medicine providers to help screen for high-risk HF factors that need to be referred to specialists. “If anything, it's just reaching across the aisle so to speak, and having the conversation about what's the best for patient-centered care—not specialty-centered care, not provider-centered care. It's about patient-led care. And that really requires us to collaborate,” Malliett said.

Lastly, Malliett stressed the importance of tailoring treatment options relative to the interested quality, and quantity, of life that patients want from their advanced HF diagnosis.

“So, having clear conversations up front and really talking to your patient about, 'What's important to you? Where do you want to go on life? If you could have the best day ever, what would it look like?' and seeing if what we have to offer would fit into that is vital, because these are huge lifestyle changes that we're talking about,” she said.


  1. AHA. Advanced Heart Failure. Web page. Last updated July 12, 2023. Accessed May 21, 2024.,10%25%20have%20advanced%20heart%20failure.
  2. Yancy CW, Januzzi JL Jr, Allen LA, et al.2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2017;Dec 22:[Epub ahead of print].
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