Novel Approaches in Improving HF Management

Sheryl Chow, PharmD, BCPS; Akshay Desai, MD; Peter L. Salgo, MD; Scott Solomon, MD; and Orly Vardeny, PharmD, MS, offer their perspectives on the future of heart failure management, including care coordination improvements and dose optimization in the outpatient setting.

Peter L. Salgo, MD: Again, this goes into transitions of care. You’ve been in the hospital setting, now you’re in the outpatient setting, and this transition has to be smooth or it’s all going to just blow up. And then you’re coming back in 30 days and somebody, at the very least, is going to pay a lot of money. But it seems to me that the money is the least of the issues. Somebody is going to get sick. Are there new, novel approaches to transitions of care and coordination of care between the outpatient and the inpatient setting? What’s out there?

Akshay Desai, MD: I think there are a few. Each hospital has its own care transition strategy. We don’t have a lot of data about types of care transition strategies. People have talked about what goes in the syringe. We know that disease management works, but we don’t know what the elements are that are important. We think that every effective strategy contains some routinized discharge instructions for patients—some guidance about who and when to call for worsening symptoms, some guidance about how to recognize worsening symptoms, and some messages about adherence.

It’s also important to recognize when disease is hitting that end stage, because the other thing we haven’t even begun to touch on is what to do with the patient who can’t tolerate the medicines or who’s coming in to the hospital despite all of our best efforts. And for a small few, there are salvage therapies, including cardiac transplantation and mechanical circulatory support, but that’s the minority. And for others, a lot of care transitions emphasize palliative care engagement and hospice engagement for the select few. I think thinking a lot about where patients are in the trajectory of their illness and what support they’re going to need to stay well outside the hospital, to individualize disease management, is a big part of our responsibility as physicians.

Peter L. Salgo, MD: It seems to me there has to be a mechanism. There has to be some sort of framework into which we can fit all these patients—some accepted norm. Somebody is going to go out. You’re going to be seen by a nurse. You’re going to be seen by a physician extender. You’re going to be seen by this physician. “Here’s your schedule, and here are the things we’re going to be looking for.” To me, it’s kind of amorphous right now. Does anybody have this framework at hand?

Akshay Desai, MD: Well, I think we’re all trying to build it. In each hospital, I think you could walk down the line and hear about different approaches that have been tried. But I think we’re all trying to do exactly that, which is to create a framework into which we can drop patients as they leave the hospital, so that they’ll land softly and not end up back in the hospital.

Peter L. Salgo, MD: This has been a terrific discussion. There’s a new class of drugs coming up, and the results are very good. It implies that we need to get folks under control, under observation, into the system, so they can gain the benefits from that. Is that a fair statement?

That being said, it’s time, now, to give each of you the last word, because we’ve come a long way and I know you have thoughts. So, we’re going to go around the table and ask each of you to give a last word to our audience about what you think is important.

Sheryl Chow, PharmD, BCPS: Overall, I think that it’s very impressive that 2 new medications have been approved for the treatment of chronic heart failure over the last couple years. So, it’s amazing. They have different outcomes, but both benefit patients with heart failure. We have new strategies, new completely different mechanisms of action, first-in-class, that are very interesting. And you have guidelines that are supporting it. The problem is, you can have all the guidelines and recommendations you want, but if you don’t start your patient on the medications, there isn’t going to be an improvement in patient outcomes. That’s my thought.

Peter L. Salgo, MD: Dr Desai?

Akshay Desai, MD: I think this is an exciting time for heart failure management. We haven’t had new drugs in a long time, and I think the availability of new drugs really reminds us that we have an obligation to apply the old drugs. I think there is a need to recognize heart failure in all of its forms. It’s important to identify those patients with reduced ejection fraction, where we have effective therapy, and to apply that therapy consistently to improve outcomes. This is a mortal disease, but it’s one that can be modified over time.

Peter L. Salgo, MD: Dr Solomon?

Scott Solomon, MD: Maybe I’ll spend my minute talking about unmet needs, because we’ve spent most of the time talking about heart failure with reduced ejection fraction (HFrEF), for which we are very fortunate and have evidence-based therapies. But there are other disorders that we don’t. Heart failure with preserved ejection fraction (HFpEF) is one where we’re still looking—there are trials that are ongoing. In fact, with the ARNI (angiotensin receptor neprilysin inhibitor), there’s a large trial called PARAGON-HF that’s testing this as well. We also know that there’s potential in the post-myocardial infarction setting, so there are trials there as well. In acute heart failure, unfortunately, we haven’t had success. There have been a few notable failures in this area, and we still need a way to make patients feel better and also transition them when they come in with acute decompensated heart failure. So, we’ve made a lot of progress in HFrEF, but we haven’t made progress in acute decompensated heart failure or HFpEF. That’s where I think we need success.

Peter L. Salgo, MD: And the last word goes to you, Dr Vardeny?

Orly Vardeny, PharmD, MS: I think I’m going to bring it around to the hospital. We started off by saying that hospitalization is the most burdensome outcome in terms of patients with heart failure. But one of the things that we can do to impact hospitalizations or reduce them is to optimize management in the outpatient setting. That means we need to give patients the opportunity to be on good guideline-based doses of all of the drugs that we talked about. The new drugs and the old drugs, as Akshay was saying, should be evaluated, and patients should have the opportunity, or deserve, to be on the right doses of those as well.

Peter L. Salgo, MD: Well, I’ll tell you, from my perspective, listening to this discussion is exciting. There are a lot of diseases out there that, when I was in medical school, we just wrote off. “There is nothing we can do. See you tomorrow” or “See you in a month,” this is not true anymore. Now, we have really good stuff—really new medications with evidence-based effects, and they work. That’s exciting, from my perspective. I’m delighted to be in a profession where we can say that things are moving forward, things are going the right way. I want to thank all of you for being here and sharing that with us. I want to thank you for joining us as well. I’m Dr Peter Salgo, and I’ll see you next time.