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When it comes to controlling the many comorbidities that burden CHF patients such as renal dysfunction, pneumonia, and diabetes, is the patient better off under the care of a cardiologist or that of a primary care physician? CHF Disease Management asked several experts to share their thoughts on the Chest article (1999; 116(2):346-354), and found they had differing opinions.
"Maybe the primary care physician is better equipped to handle comorbidities than the specialist. Cardiologists tend to focus on the heart and what’s going on there, where the general practitioner may look at the whole picture." — Bobby Miller, supervisor of the Optum Disease Management Program in Dayton, OH.
"It depends on how up to date on the literature the doctor is. For example, for renal insufficiency, it’s been shown that if you add an ACE inhibitor, the patient lives longer. But if you’re not up on that, and you add an ACE inhibitor and the BUN creatinine goes up, you might discontinue the ACE inhibitor. That’s the wrong thing to do." — Gordon Ewy, MD, chief of cardiology at the University of Arizona Health Sciences Center in Tucson.
"Primary care physicians may be better at dealing with comorbidities than cardiologists. The best scenario for a nonadvanced patient may be treatment by a primary care physician in conjunction with a cardiologist, not a cardiologist taking over the care. Consultation with a cardiologist works out the best." — Santosh G. Menon, MD, a cardiologist in the division of cardiology at the University of Kentucky in Lexington.
The study’s lead author, Edward F. Philbin, MD, a cardiologist at Henry Ford Hospital in Detroit says, "For the heart failure patient with comorbidities, the best way to go is probably for him to be cared for by a primary care doctor with a cardiologist consult. There’s value in teamwork and continuity of care." He says he thinks primary care physicians might take better care of comorbidities such as diabetes since the specialist tends to focus on his specialty. "That’s speculative, though," he says.