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Slide 8

Prescribing Decisions

Reducing Hospitalizations and Improving Patient Outcomes in Heart Failure Management

Barriers include coverage (i.e. for newer agents especially) and patient (and at times provider, possibly due to unfamiliarity) reluctance. Steps to take are helping informed decision making with rationale behind multiple drugs explained, and looking into any assistance available for coverage.

Slide 6

Prescribing Decisions

Reducing Hospitalizations and Improving Patient Outcomes in Heart Failure Management

I believe the biggest barrier is related to the cost of the medication. The generics are easy to prescribe for patients to get however, the SGLT2i and the ARNI’s usually have a high co-pay and patients say they can afford it. There are programs that the drug companies have over. This does not apply to Medicare patients who are the more most likely patients to have congestive heart failure. If there is something we could do for these patients it would be very helpful to keep patients on GDMT.

Slide 5

Patient Care

Reassess. Intensify. Protect: Timely LDL-C control post-MI can prevent what comes next

It takes a village... close follow-up after discharge and almost always more than one drug in combination therapy for lipids, inflammation, and anti platelets are needed. Along with cardiac rehab, nutrition modification, and lifestyle modification. Very frequent touchpoint and lab measurements are needed often in the initial phase and then for the long term.

Slide 4

Patient Care

GDMT Optimization: A High-Intensity Care for Heart Failure

There is no question from the data that quadruple therapy is imperative. One of the challenges that I have found in achieving quadruple therapy as well as appropriate dosing is that many patients are cared for by multiple caregivers. Often a patient may be seeing a cardiologist as well as their primary care physician and nephrologist, and there are different goals of each of those caregivers.

I have seen situations where either the primary care physician or a physician extender cut back on a patient's medical regimen telling them that they didn’t need to be on several blood pressure medications or that their blood pressure was well enough controlled with a certain dose of beta blocker so there was no need to increase it.

Part of the challenge is explaining to the patient and their pcp team that the regimen they are on is not for treatment of their blood pressure even though several of the medicines are given for blood pressure as well, but rather the goal is maximization of dose and completion of the four-drug regimen in order to achieve maximum benefit.

Slide 3

Patient Care

GDMT Optimization: A High-Intensity Care for Heart Failure

I first express the importance of all of the GDMT medications to the patients even if they are not symptomatic. I like to initiate an ARNi and beta blocker with an SGLT2i. After I see how the blood pressure reacts in about a week I bring the patient back to the office and perform an MRA. I look to see if the patient develops symptomatic hypotension and use midodrine if needed. If Cr rises I would decrease the diuretic and make sure the patient is well hydrated. Would only adjust beta blocker if HR falls below 50 or the patient experiences severe fatigue. The other strategy I use is to ask the patient to take their medications at different times of the day to "spread out" the hypotensive effects.

Slide 1

Prescribing Decisions

Updated guideline for heart failure

My practice has gotten in line with the guidelines for the most part. Using primarily COR 2a recommendations and higher. DATA really are strong for these newer agents, and it’s especially refreshing to have a therapy for HFPEF finally. I agree with other posters that beta blockers should be the first option, however I will use calcium channel blockers as an add on if there is no significant clinical improvement. That being said, many patients will still be short of breath with exertion in spite of incremental therapy.

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