FOCUS ON: HEART FAILURE
Roundtable Renews
Focus on Management
of Heart Failure
T
he complexity and challenges of treating patients with heart failure (HF)
took center stage at ACC’s Heart House
headquarters in Washington, DC, during a recent
roundtable designed to explore the day-to-day issues facing health care providers across the spectrum and to identify knowledge gaps, barriers to
coordinated care, outcomes and their measurement, and solutions to help the clinical community. Such roundtables are held by the College
to provide a forum for a multidisciplinary group
of experts to inform the development of clinical
policy in clinical areas where guidance is needed
because of evidence that is limited or evolving, or
new therapies alter the landscape.
The Emerging Strategies for HF Roundtable
was held at a true crossroads: approval of two
drugs for treating HF; and publication of a
focused update to the full HF guidelines incorporating these new treatments by the ACC and
American Heart Association (AHA).
For the first time in a decade, two new treatments have been added to the HF armamentarium, simultaneously raising expectations for improved care and concerns for a further increase
in the complexity of patient care. Sacubitril/valsartan, an angiotensin-receptor neprilysin inhibitor, represents a particular challenge, because it
is not another add-on therapy, but a replacement
therapy for a renin-angiotensin system blocker.
Although it has been shown to bring substantial benefit to ambulatory patients who remain
symptomatic despite optimal medical therapy,
the steps to incorporate it into treatment requires
education and new care pathways. Ivabradine, a
heart-rate reducing agent, provides another option to improve outcomes in stable, symptom atic
HF patients with reduced ejection fraction with
heart rates above 70 beats per minute.
Led by Clyde Yancy, MD, chair of the ACC/
AHA HF guideline writing committee and chief
of cardiology at Northwestern University, and
James Januzzi Jr, MD, chair of the ACC’s Expert
Consensus Decision Pathways Task Force and
chief of cardiology at Massachusetts General
Hospital, experts representing physicians from
internal and family medicine to hospitalists,
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CardioSource WorldNews
cardiologists, and HF
specialists, emergency
medicine, nurse practitioners, and clinical
pharmacy, were complemented by representatives of health informatics, industry, payers
and policymakers. HF
patients also were active
participants.
What’s complex
about managing HF?
The multiple phenotypes of HF combined
with the multiple (5+)
comorbidities with
which the typical
patient presents along with a health care delivery system that is fragmented and often marked
with poor transitions in care presents a host
of challenges, each requiring a set of solutions.
Moreover, the current focus on preventing 30day hospital readmissions is a financially driven
goal that rewards short-term management at the
expense of long-term patient management.
Patient-centered care that matches therapy to
the goals of the patient derived through shared
decision-making and guided by evidence-based
tools and algorithms streamlined for application
at the point-of-care is needed. Integration of this
management through a medical home, perhaps
a heart team led by a HF specialist, with performance measures that include patient-reported
outcomes and preferences along with care transitions, may represent the way forward.
While HF resulting from coronary artery
disease is decreasing, it is more frequently arising
from other etiologies, such as chemotherapy and
hypertension. Indeed, controlling hypertension to
reduce the transition to worsening HF represents
one of the greatest, but unrecognized, opportunities to reduce the incidence of HF. This requires
a shift in focus to HF being a preventable disease.
Diabetes and its frequency in HF patients and its
impact on macrovascular disease is an increasing
concern, which may in part be addressed by a
new class of antidiabetic drug with recent evidence for reducing HF and hospitalization. But,
as with the new HF drugs, incorporating this into
clinical practice is a current challenge.
Harnessing data science for detection algorithms, risk assessment, referral for advanced HF
care, and leveraging registries, and information
technology to create treatment algorithms and
care pathways that are integrated within usual
care were among recommendations from the
multidisciplinary group. Precision tools, based
on pharmacogenomics and phenotyping, require
development. Organizations and stakeholders
for collaborative work, such as determining data
needs for pharmacogenomics in HF, and addressing cost and insurance authorization hurdles,
were highlighted.
This timing provided a pivotal opportunity for
stakeholders to discuss a full range of practical
issues in HF management and inform ACC efforts
to improve care by developing clinical and patient
tools and resources.
The robust and information-rich discussions and numerous recommendations from the
experts is being used by the ACC for the development of expert consensus decision pathways
and clinical and patient tools. More information,
including video wrap ups of each Roundtable session can be viewed at ACC.org/HFRoundtable. ■
September 2016