ACC Expert Consensus Decision Pathway for HF Treatment

James Januzzi, MD: To be clear, there are far more expert consensus decision pathway documents than the ones just focused on heart failure. These documents were not created as a competition for the guidelines. Guidelines tell us why we should do something, but the expert consensus decision pathway documents are more focused on how to implement, how to use the things that we should be using on the basis of guideline recommendations. The American] College of Cardiology recognized there was a need for guidance at the point of care. This is knowledge that can be used in the emergency department or in the hospital, but for this document specifically, in the office. It provides a wide range of information not just about drug therapy in heart failure, but a number of other topics.

Javed, we were both involved in the curation of the outpatient heart failure document. As a clinician, I think it contains a lot of really useful information. As I said, it’s not just about drug therapy. Before we dive into the consensus algorithm, why don’t we talk a bit about the document as a whole, holistically speaking? Let me ask you a couple of questions. You were involved in some of the considerations around the nuances of how to use medication in the patients we see. For example, management of the increasing complexity of heart failure was one of the topics that we addressed in this. It’s not just a list of medications and doses, but more thinking about the patient. As a clinician yourself, when you look at the drugs that we have to administer and you see the complexity in our patients, do you have any general points of view about the complexity of patients we’re seeing before you initiate therapy?

Javed Butler, MD, MPH, MBA: Yes. It doesn’t matter which type of a clinician you are, whether you’re a nurse, doctor, pharmacist, or a nutritionist. We all know that the clinical trials aren’t an exact fit for the person sitting in front of you. That’s where this whole notion of the art and science of medicine comes up. One way to think about it is that the guidelines are the science of medicine, and these pathways are the part of medicine that helps you figure out how to translate that evidence into treating the patients sitting right in front of you.

Our patients are older and have many more comorbidities. They have lower blood pressure, differences in their renal function, liver function, what have you. Then there are a whole lot of social issues as well: whether they have a support system, have somebody taking care of them, their insurance, their educational level. Can they adhere to their recommendations? Do they understand the recommendations that you are giving? Real life is more complex than the life we create in a clinical trial setting. That’s where these documents become really important. It gives you a little bit of a road map to think through these complex issues when you are trying to implement these therapies we have learned about in a more idealistic setting of a clinical trial.

James Januzzi, MD: Yes, that’s really helpful. Once we unpack the background of the medical therapies that we’ll be talking about and the new changes in the algorithm, maybe we can talk about the nuances: in whom you might go more rapidly or more slowly, which drugs you might lead with. These are just recommendations. They’re not hard and fast rules, so there is some leeway given to clinicians to make decisions about timing, speed, and other nuances to the choices of therapy that we give.

Transcript Edited for Clarity