Challenges in Heart Failure Management

Anuradha Lala-Trindade, MD: Managing heart failure in the United States is riddled with challenges. I tend to be an optimist, but we have to call a spade a spade. I think there are several aspects of why it is so challenging to manage heart failure. One, I think we recognize that hospitalizations for heart failure are exceedingly common. It's the most common reason for hospitalization in patients over the age of 65. Number 2 is, once a patient is hospitalized, the readmission rates are exceedingly high. That tends to be a benchmark by CMS [Centers for Medicare & Medicaid Services] and other governing bodies in terms of evaluating quality of care, which is controversial in and of itself. One in 4, and that's being conservative, are readmitted within 30 days. So you not only have a high burden of primary hospitalizations, but then a high burden of those rehospitalizations as well.

Then you run into the transitions of care models, which are very challenging because it's not a one-size-fits all recipe to prevent readmissions. It depends on the institution, the population served, and access to care. So there's essentially different recipes that probably fit best with different institutions. I think that's part of the reason we haven't found one specific recipe that works for all comers in terms of transitions of care models. What does work is really in-hospital management and initiation of the medications that we know work. But we'll come back to that because we're sticking to the challenges.

Then, lastly, is the economics of this. I think the costs that are associated with the care of patients living with heart failure is astronomical. It's upwards of $30 billion to $40 billion currently and expected to be over $70 billion in the United States by 2030. So, really, you're talking about just very high burden, both from a quality-of-life perspective, survival perspective, readmissions and admissions perspective, and then from the economic burden perspective.

I think the new universal definition of heart failure, published in 2021 in the Journal of Cardiac Failure, was really a very important step in advancing our field forward. And why is that? I think because it draws so much meaning and importance to the words we use to describe heart failure. And I think there's subtle differences. They may seem subtle to some, but I think they're actually quite profound.

First, it emphasizes the spectrum-like nature of the ejection fraction. What used to be called intermediate ejection fraction from 41% to 49% is now called mildly reduced ejection fraction. And a lot of the same is seen in the new guidelines that were published in 2022 by the ACC [American College of Cardiology], AHA [American Heart Association], and HFSA [Heart Failure Society of America] guidelines. But I'm specifically speaking about the new universal definition from a year prior because its focus was on the language we use to describe patients living with heart failure in different arenas. So, one was the change of intermediate ejection fraction going to mildly reduced. Again, you can see you have reduced ejection fraction, then mildly reduced, and then into the preserved field. So it's emphasizing that spectrum-like nature of ejection fraction. That's really important.

Second is that we have this notion of moving away from the word recovery and focusing on the fact that you can enter remission with heart failure if optimized on guideline directed medical therapy, and device-based therapies that are evidence-based, and you no longer have symptoms. We borrowed this nomenclature from our oncology colleagues. So you can have heart failure, be symptomatic, be optimized from a both pharmacologic and device-based perspective, and then have heart failure in remission. It doesn't mean you get rid of your heart failure, but your symptoms are in remission. I think it's the sweet spot between conveying to your patient that you still have the diagnosis, but now you don't have symptoms so you're in remission. And I think that patients are able to receive that information easier than if we would say, you have heart failure. And then they would say, hey, but we don't feel poorly. So that's the second thing.

The third thing is, along those lines, if you remain symptomatic despite efforts at optimizing device and pharmacological therapy, then you have persistent heart failure or heart failure with persistent symptoms. So that makes very logical sense. I think the other aspect of this is that you now have an opportunity to be more specific about what happens to those individuals who previously had a reduced ejection fraction that has now improved or increased to potentially even being in the preserved category. We call those patients heart failure with improved ejection fraction. And that's a subtle distinction, but an important one because it differentiates from what we used to use, which was recovered ejection fraction. Or saying you have recovered, period.

What we used to do by using that verbiage is we would deprive patients of the medical therapy we know that they need to continue. And so, I think by saying that you have heart failure with improved ejection fraction, you don't lose sight of the fact that it was once reduced. I think that that was a really important element of the new universal definition. Those are some of the broad strokes that I would say are important, and it allows you to understand who's going to respond to what therapy across the spectrum of ejection fraction.

Transcript edited for clarity