Heart Failure & Hypertension: What Primary Care Can Do Earlier

Heart failure and hypertension are conditions primary care providers encounter every day, but identifying that risk early – and knowing when to escalate care – can make a meaningful difference in patient outcomes. 

In RubiconMD’s recent Grand Rounds CME Webinar, “Heart Failure & Hypertension: Early Intervention in Primary Care,” cardiovascular medicine specialist Dr. Mohamed Morsi, Associate Professor of Cardiovascular Medicine at the University of Virginia Health System, shared a practical, primary care-focused framework for recognizing heart failure, managing guideline-directed therapy, treating hypertension in older adults, and determining when an e-consult can add value. Want the full clinical deep dive? Watch the on-demand webinar here: Heart Failure & Hypertension: Early Intervention in Primary Care.

Recognize heart failure before it becomes advanced. 

Dr. Morsy emphasized the importance of recognizing where a patient falls along the heart failure spectrum. Understanding the four stages can help primary care providers identify risk, recognize disease progression, and determine when intervention or specialist involvement is needed.  

• Stage A (At RIsk): Patients have risk factors such as hypertension, diabetes, family history, or prior exposure to cardiotoxic chemotherapy, but no symptoms, structural changes, or evidence of cardiac injury.
• Stage B (Pre-Heart Failure): Patients have structural heart changes, such as left ventricular hypertrophy or chamber dilation, or evidence of elevated filling pressures or cardiac injury, but remain asymptomatic. 
• Stage C (Symptomatic Heart Failure): Patients have current or prior symptoms of heart failure, such as edema, dyspnea, crackles, or elevated JVD, associated with structural or functional heart disease. 
• Stage D (Advanced Heart Failure): Patients experience severe symptoms that interfere with daily life despite optimized treatment and require advanced specialty care, including evaluation for mechanical circulatory support or transplantation. 

For primary care teams, this reinforces an important point: heart failure prevention and early recognition begin well before a patient presents with overt symptoms. 

When evaluating a patient with suspected heart failure, Dr. Morsy recommends focusing the physical exam on two questions: is the patient congested, and are they adequately perfusing? 

Signs of congestion can include edema, ascites, elevated JVD, and rales. Signs of poor perfusion may include cold extremities, changes in alertness, or evidence of kidney dysfunction. Dr. Morsy also highlighted an important distinction during diuresis: a rise in creatinine alongside improving edema may reflect hemoconcentration during effective decongestion, rather than true acute kidney injury. A rise in creatinine without improvement in congestion warrants closer evaluation for possible kidney injury or inadequate perfusion. Considering these findings together can help clinicians determine the patient’s clinical status and guide next steps. 

Treat heart failure systematically – but individualize care. 

Once heart failure has been identified, Dr. Morsy discussed the importance of guideline-directed medical therapy, particularly for patients with reduced ejection fraction. 

For HFrEF, the four major medication classes discussed were: 

• ACE inhibitors, ARBs, or ARNI
• Evidence-based beta blockers
• Mineralocorticoid receptor antagonists (MRAs)
• SGLT2 inhibitors 

Dr. Morsy stressed that early initiation and rapid sequencing of guideline-directed therapy are important, rather than waiting to fully optimize one medication before introducing another. He outlined an approach that begins with an SGLT2 inhibitor and an ACE inhibitor, ARB, or ARNI at the first visit, followed by the addition of a beta blocker approximately two weeks later and an MRA approximately two weeks after that, as clinically appropriate. Blood pressure, kidney function, potassium levels, medication tolerance, adherence, and other patient-specific factors all influence how quickly therapy can be advanced. 

For patients with HFpEF, the approach is different. SGLT2 inhibitors have an important role, while management also focuses on controlling blood pressure and congestion and addressing contributing conditions. 

The broader takeaway: guideline-directed therapy provides the framework, but applying it effectively requires clinical judgement and ongoing reassessment. 

Don’t overlook the factors that complicate heart failure.

The webinar also highlighted several conditions that can influence heart failure management and outcomes. 

Iron deficiency is one. Dr. Morsy emphasized the importance of screening for iron deficiency in patients with heart failure, noting its impact on quality of life and mortality. 

Sleep apnea is another important consideration. Patients with hypertension, obesity, or atrial fibrillation may warrant screening, particularly given the relationship between sleep apnea and cardiovascular disease. 

For primary care organizations, these considerations reinforce the value of looking beyond the heart failure diagnosis itself. Managing the conditions surrounding heart failure can be just as important as managing the heart failure regimen. 

Hypertension management may require a different approach in older adults.
For older patients, Dr. Morsy discussed balancing blood pressure control with the risks associated with overtreatment, including dizziness and falls. 

While a target of less than 130/80 may be appropriate in many patients, he noted that a more permissive blood pressure target of up to 140/90 may be reasonable for select older adults, particularly when tighter control increases the risk of dizziness, falls, or other adverse effects. 

He also emphasized reviewing medications and other factors that may contribute to elevated blood pressure. NSAIDs and decongestants, for example, drive blood pressure higher and may be easy to overlook during routine medication reviews. 

When hypertension remains uncontrolled despite an appropriate medication regimen, clinicians should consider resistant hypertension and investigate potential secondary causes, including obstructive sleep apnea, kidney disease, thyroid dysfunction, renal artery stenosis, and primary hyperaldosteronism. 

Knowing when to ask for specialty input. 

One of the most practical portions of the webinar focused on when an e-consult can help, and when it is not the right tool. Dr. Morsy identified several scenarios where a cardiology e-consult may be appropriate, including: 

• Difficulty titrating guideline-directed heart failure therapy, including how to adjust the four medication classes when blood pressure drops or creatinine fluctuates 
• A decline in ejection fraction, including questions about next steps in management 
• Persistent edema despite optimized oral diuretics, with questions about next steps when patients aren’t responding to treatment 
• Questions about interpreting BNP, particularly in patients with comorbidities such as obesity or chronic kidney disease 
• Uncertainty around HFpEF, including use of the H2FPEF score to support diagnostic evaluation. Patients with obesity, atrial fibrillation, and hypertension may warrant closer assessment for HFpEF and coexisting sleep apnea
• Questions about whether a patient may need a CRT or ICD, particularly when declining ejection fraction raises concerns about device candidacy 
• Medication intolerance, including identifying alternatives when standard guideline-directed therapy causes adverse effects 
• Hypertension medication selection or regimen optimization, particularly when standard therapies are not controlling blood pressure 
• Questions about secondary causes of hypertension, including how to evaluate resistant hypertension and determine appropriate next steps in the workup 

At the same time, e-consults are not a substitute for urgent evaluation. Certain clinical presentations may require immediate in-person or emergency assessment, such as signs of cardiogenic shock (cold extremities and altered mental status), severe or refractory volume overload, syncope in the context of heart failure, rapidly declining blood pressure, orthopnea, or severe dyspnea on exertion.

For primary care teams, this distinction matters. The goal isn’t to refer every complex question out. It’s to recognize when targeted specialty guidance can help move a patient forward, and when a patient needs in-person or emergency evaluation. 

Bringing specialty expertise closer to primary care. 

Heart failure and hypertension management often requires nuanced decisions that don’t always fit neatly into a guideline or a single visit. Primary care providers need access to specialty expertise without necessarily sending every patient for an in-person consultation. 

That’s where an e-consult can become a practical extension of the primary care team.

By connecting PCPs with specialists for focused clinical questions, RubiconMD helps organizations give providers access to the expertise they need to make informed decisions, manage more complex patients, and determine when a traditional referral is truly necessary. 

The earlier primary care teams can recognize risk, act on clinical changes, and access the right expertise, the more opportunities they have to intervene before patients progress to more serious disease. 

Interested in learning more about how RubiconMD can support your primary care organization with on-demand specialty expertise? Connect with our team.