Eiran Gorodeski, MD, MPH, is a professor of medicine and section head of the section of advanced heart failure at Case Western Reserve University School of Medicine, as well as the director of the advanced heart failure and transplant center at University Hospitals.

Eiran Gorodeski, MD, MPH

Multidisciplinary Care and Addressing Pill Burden in HF, With Bernard Kadosh, MD, and Eiran Gorodeski, MD, MPH

 care has become increasingly multidisciplinary, as clinicians from the myriad specialties that affect it come together to address common issues faced by patients, including comorbidities, pill burden, and outcomes.

Several clinical guidelines in recent years have emphasized the importance of multidisciplinary teamwork in the prevention and treatment of HF. In addition to specialists and HF nurses, recommendations encourage primary care physicians to enter the fold as well, making care more accessible in locations which may be limited in their access to specialization.

“We need to demystify heart failure treatment,” Bernard Kadosh, MD, medical director of the ventricular assist device and cardiogenic shock programs at NYU Langone Health, told 

 in an exclusive interview. “You don’t really need an advanced heart failure physician to treat most patients with heart failure. We’re here to lift up the patient when they get to the stage where they may need a little bit more help than what GDMT is able to provide for them. Most of the workforce that will be touching a heart failure patient will probably be internists, primary care physicians, and general cardiologists. It’s incumbent upon us as specialists to make care easier and more accessible.”

Multidisciplinary care can also allow easier access to HF specialists, as primary care providers and other non-specialty clinicians and nurses can conduct non-pharmacological treatment methods. Additionally, multidisciplinary teams can be adapted to several different service models, allowing clinics to address patient concerns at any level.

Increasingly high on the list of concerns in HF treatment is pill burden. In recent years, the manifold prescription medications for various treatments, coupled with a rising distrust in the medical industry at large, have fueled the burden of taking multiple HF drugs among patients.

Recent studies have highlighted the degree to which pill burden affects patients with HF, determining significant variance depending on clinical and psychosocial factors. Additionally, the study discovered that higher burden of treatment increases the risk of adverse health outcomes as a result of lower adherence.

Pill burden is often attributed to the sheer number of crucial HF therapies, including the 4 main pillars of ARNI, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors. In combination, these drugs provide optimal prevention and maintenance of HF – however, all 4 pills are often not taken in conjunction. This naturally increases a patient’s risk of hospitalization, complications, and eventually mortality.

“Patients are willing to take all types of supplements and vitamins, but when you tell them they’ll need to be on 4 medications for heart failure, their eyes are wide open and they’re shocked,” Eiran Gorodeski, MD, MPH, professor of medicine and section head of the section of advanced heart failure at Case Western Reserve University School of Medicine, as well as director of the advanced heart failure and transplant center at University Hospitals, told 

. “First of all, we need to acknowledge the pill burden – to ignore the pill burden will fuel distrust. And then, I think the next step is to explain why those therapies are lifesaving. They reduce the risk of getting hospitalized, they may help the structure of the heart improve, and they improve survival.”

Editors’ Note: Kadosh and Gorodeski report no relevant disclosures.

McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. 

Smith JL, Killian JM, Shippee N, et al. Burden of treatment in patients with heart failure. Journal of the American Heart Association. 2025;14(10). 

Videos

Kadosh and Gorodeski discuss the value of including non-specialists in HF care and the challenges of prescribing 4 pills in a time of increasing medical distrust.

Improving Heart Failure Awareness and GDMT Prescription, With Bernard Kadosh, MD, and Eiran Gorodeski, MD, MPH

Recent studies have highlighted shortcomings in both patient awareness and guideline-directed medical therapy (GDMT) prescription in 

HF is a condition with an enormous patient population, affecting >6 million adults in the US and 64 million worldwide. However, research has long since shown that patients with HF have a substantial lack of understanding about the disease, including its development, definition, and trajectory. This is naturally associated with poorer outcomes, as patients are far less likely to make proper lifestyle changes if they are unaware of how it could affect them.

“Other conditions and diseases may be more linear. People get sick and they either improve or they don’t improve,” Bernard Kadosh, MD, medical director of the ventricular assist device and cardiogenic shock programs at NYU Langone Health, told 

 in an exclusive interview. “With heart failure, it’s quite different. There are points in the disease where the risk of bad outcomes accelerates, and there are points where the risk of bad outcomes decelerates. And I think that teaching patients about that aspect of the disease is very important.”

A 2023 study from the American Heart Association (AHA), conducted via a survey of sociobehavioral measures across study participants with HF, highlighted the significant percentage of patients who are unaware of their diagnosis. This questionnaire, consisting of 1 question asking if patients had or had experienced 

Of the survey recipients, 1114 completed the survey; of those who responded, 71% had validated HF (n = 787). These patients were included in the analysis, which ultimately proved that 37% were aware of their diagnosis (n = 293). After adjustment, the study found that being a woman (OR, 1.56; 95% CI, 1.1-2.22), having HFrEF (OR, 1.58; 95% CI, 1.13-2.22) or coronary artery disease (OR, 1.65; 95% CI, 1.16-2.37), and attending the HF clinic (OR, 4.07; 95% CI, 2.25-7.36) were associated with increased diagnosis awareness.

Similarly, a 2022 study published in the 

examining GDMT prescription in patients with HF uncovered a substantial percentage of patients who are not given 1 or more of the 4 pillars of HF treatment, including ACE inhibitors/angiotensin receptor blockers (ACEi/ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors.

Based on an investigation of prescription history, a very small proportion (17% to 54%) are prescribed the target dose of ACEi/ARBs and beta-blockers in community settings. This has been attributed in large part to therapeutic inertia.

“Clinicians need an implementation playbook, and it needs to be protocolized in the same way as other diseases like myocardial infarction and ST elevation. These are protocol-driven therapies, and nothing is missed,” Eiran Gorodeski, MD, MPH, professor of medicine and section head of the section of advanced heart failure at Case Western Reserve University School of Medicine, as well as the director of the advanced heart failure and transplant center at University Hospitals, told 

. “We need to do a better job in creating and implementing a playbook in heart failure. Some of those playbook steps include identifying people who are admitted for compensated heart failure and then starting medications early and aggressively before discharge.”

Kadosh and Gorodeski went on to describe suggestions for clinicians in combatting these significant setbacks, educating both patients and other clinicians about this debilitating condition.

“I think it’s important to frame where the patient lies on the trajectory of the disease, and I usually do so in terms of stages,” Kadosh said. “If they come to me in Stage C, I say, ‘You have Stage C heart failure, but that doesn’t mean you necessarily will progress. There are a lot of therapies we have to help you prevent progression, to stabilize your symptoms, and to ensure that it doesn’t get worse.’ It’s our job to make sure that the patient understands the potential.”

Shropshire SJ, Fabbri M, Manemann SM, et al. Patient awareness of heart failure diagnosis: A community study. 

Rastogi T, Duarte K, Huttin O, Roubille F, Girerd N. The Prescription Pattern of Heart Failure Medications in Reduced, Mildly Reduced, and Preserved Ejection Fractions. 

Kadosh and Gorodeski discuss 2 of the major challenges facing both patients and clinicians dealing with HF and how to address them.

A pair of authors of a recent scientific statement and the president of the HFSA discuss cognitive impairment in heart failure. 

Role of Screening, Addressing Cognitive Impairment in Heart Failure Management

For some time, the heart failure community has warned of an impending storm brewing under the nose of public health despite their rallying cries and calls for a greater emphasis on management. With the aging US population as a backdrop, the prevalence of 

 is expected to grow in the coming years and, with heart failure fellowships going unfilled at an alarming rate, many in the field are concerned they are heading toward a perfect storm bent on wreaking havoc on public health.

The concern among filling fellowship slots aside, advanced heart failure and transplant specialists currently practicing have been confronting a growing concern associated with the aging population, but that could spell disaster for heart failure in particular: cognitive impairment. In their latest scientific statement, the Heart Failure Society of America has aimed at the issue and how it affects the management of heart failure.

Published on March 12, 2024, the 17-page document cites 142 references and is divided into 5 sections addressing the following subjects: risk factors for cognitive impairment, implications of cognitive impairment, management of cognitive impairment, integration of cognitive impairment into decision-making, and gaps in knowledge and challenges to implementation. In addition to calling attention to the prevalence of cognitive impairment in this patient population, the docuemnt also provides an overview of recommended screening tools and practices based on contemporary literature.

In this HCPLive peer-to-peer discussion, we spotlight perspectives on the subject from 3 subject matter experts in Eiran Gorodeski, MD, MPH, Parag Goyal, MD, MS, and James Fang, MD. In the conversation, Fang, who also serves as the president of the Heart Failure Society of America, acts as a moderator and guides Gorodeski and Goyal, who served as lead co-authors for the statement, through a discussion on the creation process, key takeaways, the complexities of heart failure management in patients with cognitive impairment, and the role of the Heart Failure Society of America and other professional organizations in aiding clinicians with incorporating changes and recommendations within these types of documents.

, director of the Advanced Heart Failure & Transplant Center at Harrington Heart & Vascular Institute in the University Hospitals Health System as well as section head of advanced heart failure in the Division of Cardiovascular Medicine and Professor of Medicine at Case Western Reserve University.

, statement co-author, associate professor of Medicine, the Founding Director of the Heart Failure with Preserved Ejection Fraction Program, and the director of the Cardiac Amyloidosis Program at Weill Cornell Medicine.

 president of the Heart Failure Society of America, chief of Cardiovascular Medicine at the University of Utah School of Medicine, and director of the Cardiovascular Service Line at University of Utah Health Care.

Relevant disclosures for Gorodeski include Dynamed Plus. Relevant disclosures for Goyal include Agepha, Axon, and Sensorum Health. Relevant disclosures for Fang include Amgen, AstraZeneca, Boehringer Ingelheim, Novartis, and 

Bozkurt B, Ahmad T, Alexander KM, et al. Heart Failure Epidemiology and Outcomes Statistics: A Report of the Heart Failure Society of America. 

. 2023;29(10):1412-1451. doi:10.1016/j.cardfail.2023.07.006

Goyal P, DiDomenico RJ, Pressler SJ, Allen LA, Gorodeski EZ. Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement. 

. Published online March 12, 2024. doi:10.1016/j.cardfail.2024.01.003

Eiran Gorodeski, MD, MPH, Parag Goyal, MD, MSc, and James Fang, MD, discuss the HFSA's recent scientific statement on the prevalence and impact of cognitive impairment on the management of heart failure. 

Eiran Gorodeski, MD, MPH

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