Heart Failure Management in the Current Era

Transcript: Deepak L. Bhatt, MD, MPH: Well, I’d like to thank all of you for this really great discussion. Before we close, I just want to give each of you a chance to provide any final thoughts about heart failure, COVID-19 [the coronavirus disease 2019], life, whatever you’d like to talk about. Scott, we’ll start with you.

Scott David Solomon, MD: Sure. This has been a great discussion. I’ve certainly learned a lot. We have talked about a lot of medications. We have to think about the importance of all of our patients with heart failure getting the proper vaccinations, especially in the current situation. In particular, the influenza vaccination. And, if appropriate, the pneumococcal vaccination. Eventually, we hope there will be a COVID-19 vaccination as well. We know that the flu does account for a significant amount of morbidity and mortality every single year in our patients with heart failure, and the flu vaccine can attenuate and prevent, or certainly lower that risk substantially.

Deepak L. Bhatt, MD, MPH: That’s a really important point. Also, congratulations, of course, on all your efforts in leading the INVESTED trial. I think we’ll learn a lot about influenza and cardiovascular disease and all of those associated issues. I’d say to the audience to stay tuned for that, eventually.

Akshay, we can turn to you next. What are the messages that you want to leave the audience with?

Akshay S. Desai, MD, MPH: I think there’s an increasing array of effective therapy for heart failure with reduced ejection fraction. We need to partner, as cardiovascular subspecialists, with our community physicians to make sure that patients receive the appropriate therapy so that they can achieve maximal longevity and improved quality of life. We should recognize that some of these therapies are most effective when they’re introduced in patients who aren’t all that symptomatic. I think sometimes the paradigm has been to introduce more therapies when patients get sicker. I think what we’re learning is that upfront therapy with these very potent medications may help stall progression of disease. So, I think early intervention is key. We need to relay the message, as a community, about the value of medical therapy and adherence to those therapies for improving outcomes. So, I think this involves a team effort.

Deepak L. Bhatt, MD, MPH: That’s really terrific. Nancy, any closing thoughts?

Nancy M. Albert, PhD, CCNS: I would just say I agree with what was said about a team effort. I’m very hopeful that down the road we may be able to do a better job taking care of the patients that we serve based on new therapies, but also based on a greater attention to transitions in care, care coordination, and getting patients involved in their own care versus them just assuming that as providers we’re going to do it all for them. When we don’t, they end up back in the emergency room, and in the hospital.

Deepak L. Bhatt, MD, MPH: Yeah, great points. George?

George Bakris, MD: I want to agree with the above and re-echo what Nancy just said. It’s clear to me that if the patient doesn’t understand what we think they understand, they’re not going to do what we want them to do. They need to be told this is a team effort. It’s kind of like the teacher and the student. We’re the teacher, they’re the student. If they want to do well, they need to do the homework. I think that’s really the way to think about it.

Deepak L. Bhatt, MD, MPH: That’s good advice.

Deepak L. Bhatt, MD, MPH: Javed, maybe we can close with you. What are your final thoughts for our audience?

Javed Butler, MD, MPH, MBA: Let me wrap this up not with a comment but with a plea to anybody who is viewing this. If I were to say there’s a patient with a systolic blood pressure of 180 [mm Hg], or a hemoglobin A1c [level] of 11, or a cholesterol level of 200, but the patient is completely asymptomatic, none of us would say, “Why don’t we just leave the patient alone and wait until the patient gets symptomatic.” Right? We treat aggressively to prevent complications of cardiovascular disease. But for some reason, in heart failure, we have made it a symptomatic disease. It is so common that the patients are not on optimal medical therapy, and we just say, “Well, the patient is doing OK. When the patient develops more symptoms, we’ll treat them aggressively.” That is just not the right way to approach it. The whole idea is to prevent them from getting worse. There is no such thing as stable heart failure, so let’s all follow the guidelines as aggressively as possible so we can prevent issues. Remember that a lot of people can die from sudden cardiac death without getting hospitalized. We don’t even get a chance to uptitrate if you’re waiting for worsening. The whole trajectory changes and the risk gets a whole lot worse once they are hospitalized. So, let’s get the patients in the outpatient setting and use guideline-directed therapy.

Deepak L. Bhatt, MD, MPH: Javed, I think that’s a critical point. You’re right. LDL [low-density lipoproteins] or blood pressure or hypoglycemia are clear triggers. You have to do something more if someone has walked into the office with a glucose level of 250 [mg/dL], or an LDL [level] of 160 [mg/dL], or if their blood pressure is 180/120 [mm Hg]. Even if they’re asymptomatic, you’re not going to say, “Oh, I’m so happy you’re doing well. See you in a year.” You’re compelled to do something. But with heart failure, especially in the outpatient setting where they’re not complaining, it’s easy to be lulled into a sense of complacency. So, that’s really a great point. We have lots of terrific therapies, ranging from relatively simple—lifestyle modification advice—to very complex medical regimens, but none of them are of value if we don’t actually implement them into practice.

Thank you, all, for a wonderful discussion. I hope the audience enjoyed it. I hope it was educational, and wish you all the best, particularly in this time of trouble with the COVID-19 epidemic. Hopefully, this segment on heart failure will help you improve the care of your patients. Thank you so much for joining.

Transcript Edited for Clarity