Failure of heart care in our care of heart failure
Medical management of patients with heart failure has exploded in the last several years with a mixture of old and new medications that are effective individually and synergistically effective when used in combination. They are referred to as the 4 pillars of medical management of CHF. Compelling literature and advocacy from our national cardiology leaders suggest that each of these 4 medication groups should be used in heart failure patients with reduced ejection fraction wherever possible. 3 of the 4 classes are now known to be appropriate for heart failure patients with preserved ejection fraction. Furthermore, it is now recognized that these medications can be started or increased in the inpatient setting in many cases. We now have a roadmap for medication management goals for all of our hospitalized heart failure patients.
This is a good time to see what our real-time is on our heart failure patients now that we know a nationwide best practice to which we can evaluate ourselves.
For review, the four cornerstones include an MRA, an angiotensin system blocker, a beta-blocker and an SGLT2 inhibitor. The MRA most commonly used is spironolactone, and generally hyperkalemia that cannot otherwise be managed is the principal barrier to using it in HFrEF patients. As a generic medication, cost is not a barrier, and no dose titration is needed.
A second pillar are the SGLT2 inhibitors – brand names Farxiga and Jardiance – that are highly effective. They also need no dose titration (10 mg once a day for each one), additionally help with reducing high potassium levels making other aspects of care easier to institute, but their cost is a barrier. They are generally not used in end-stage renal disease or with very low GFR’s, below 20 or 30.
A third group includes, the angiotensin system blockers, include ACE inhibitors and ARB’s that everyone is familiar with for treating hypertension. These are generic and although commonly used in heart failure, they are often prescribed in lower doses than recommended for maximal efficacy. The most powerful agent in this pillar is sacubitril-valsartan, which is an ARNI and sold under the tradename Entresto. It is considered superior to ACEI’s and ARB’s and national guidelines recommend switching to an ARNI from an ACE or ARB but a notable barrier to doing that is the high medication cost.
The final group includes beta-blockers which turned out to be fairly widely prescribed in our heart failure patients. However, a smaller percentage of patients are titrated to the right dose and some patients are not taking one of the 3 beta-blockers formulations known to be effective.
A significant development making prescribing easier than before is that 3 of these 4 pillars are now known to be effective for the “lost group” of heart failure patients, those with preserved ejection fraction for whom we previously had no universally agreed-upon therapies. Other than the MRA group, all three other pillars are now recommended for patients with HFpEF. So you almost don’t need to know the ejection fraction begin or enhance the medication regimen.
Now back to our real-time scoring. An Epic search of our current heart failure patients and their medications tells us how we are doing with our hospitalized patients. This is a key group in our management for several reasons. First, these are typically our sickest heart failure patients, and being hospitalized gives them a high expected mortality as well as a high likelihood of being readmitted. Secondly, we see many patients entering the hospital not already on medications that are indicated, suggesting that in many cases our prehospital management is not optimal throughout the spectrum of outpatient care they had received. Thirdly, it is clear that if these medications are not started in the hospital when care gaps exist, therapeutic inertia makes it unlikely that they will be started in these same outpatient environments our patients came from. We have a responsibility to these people to act when they are hospitalized.
Following a presentation about pharmacologic heart failure management from a Yale pharmacist that was simulcast to all of our hospitals, we took advantage of Epic’s capabilities and did a spot check of our heart failure patients. A one-day analytic picture showed that we had 87 patients in the hospital with a diagnosis of heart failure. Looking at the 4 pillars, our scores were as follows:
Beta blockers – 26/87 (30%)
MRA – 7/87 (9%)
ARNI – 4/87 + ACEI/ARB – 4/87 (T=11%)
SGLT2 inhibitors – 2/87 (2%)
There are no conclusions here, as not all of the diagnoses may have been correct and there were likely some patients with contraindications to some of these treatment. However, since around 10% or fewer of our patients were getting any of the last 3 pillars, and no indicated treatment was provided in any more than 30% of our patients, we know there are opportunities to do better.
It is time to step up our game and recognize opportunities to improve the medication management of our heart failure patients. This applies in the inpatient and outpatient setting. Greater efforts are being devoted to education of our inpatient staff, evaluating and monitoring our performance on a regular basis, engaging cardiology leadership, and collaborating with pharmacy for patient education and ways to afford some of the expensive medications after discharge.
We need the same passion on the outpatient side. Both cardiologists and primary care physicians say they have too little time to do this well and regularly. That is true. But it is also true that lives are at stake, and we must find a way to do a better job. That will involve all of us working together, collaborating, sharing ideas, and at the end of the day congratulating ourselves when we see a job well done. We hope to get there and to get there soon.
