title: An international survey to assess referral thresholds for destination therapy in non-inotrope-dependent patients: results of the CONSENSUS-DT study.
abstract: BACKGROUND
  Criteria for the identification of patients who may progress to advanced heart failure (HF) have been previously suggested. However, identification of appropriate non-inotrope-dependent (NID) patients for destination therapy (DT) remains a challenge, and referral rates are low. We surveyed expert provider opinion about patient selection for early DT.
  
  
  METHODS
  An internet-based survey was sent to international HF providers to investigate opinions about clinical indicators for referral of NID patients for DT. Subjects were identified from membership lists of HF professional organizations. Respondents provided their level of agreement with the use of a 5-point Likert Scale (1 = strongly disagree to 5 = strongly agree) to 10 clinical criteria describing at-risk NID patients.
  
  
  RESULTS
  A total of 231 respondents who had been in a position to recommend left ventricular assist device (LVAD) therapy for 7.6 ± 5.8 years identified themselves as HF providers: 41% HF cardiologists, 27% HF nurse practitioners, 21% cardiothoracic surgeons, 9% LVAD coordinators, and 2% general cardiologists. More than two-thirds of the respondents agreed or strongly agreed with 7 of the 10 items. Similar consensus was not seen for 6-minute walk (6MW) or B-type natriuretic peptide (BNP). When asked which criteria would have to be present for LVAD referral, only hemodynamic deterioration reached ≥50% affirmation among respondents. No criteria reached >50% response as being sufficient alone for DT.
  
  
  CONCLUSIONS
  We describe referral thresholds for early LVAD therapy among international HF providers. With the exception of BNP and 6MW, we found overall agreement on the proposed clinical parameters. Despite apparent consensus, in practice implantation rates for LVAD in NID patients remain low. The results of ongoing clinical trials in this population may lower thresholds for early referral for DT.
authors.affiliation: Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Electronic address: mgalvao@montefiore.org.
authors.forename: Marie
authors.initials: M
authors.lastname: Galvao
authors.affiliation: Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Omar
authors.initials: O
authors.lastname: Saeed
authors.affiliation: Department of Educational Leadership and Human Resource Education, University of Louisville, Louisville, Kentucky.
authors.forename: Jason
authors.initials: J
authors.lastname: Immekus
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Goldstein
authors.affiliation: US Medical,Critical Care, Novartis Pharmaceutical, East Hanover, New Jersey.
authors.forename: Simon
authors.initials: S
authors.lastname: Maybaum
mesh_terms: D003625:Data Collection / Q000379:methods*; D005260:Female; D006282:Health Personnel / Q000639:trends*; D006333:Heart Failure / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D006353:Heart-Assist Devices / Q000706:statistics & numerical data / Q000639:trends*; D006801:Humans; D038622:Internationality; D008297:Male; D009200:Myocardial Contraction / Q000502:physiology; D012017:Referral and Consultation / Q000639:trends*
keywords: Heart failure; inotropes; left ventricular assist device