Joshua Remick, MD, is a cardiologist with Providence Health & Services.

Joshua Remick, MD

Although guidelines and therapies have made significant advancements in recent years, 

 care still regularly contends with adherence issues, access to treatment, and more of the same barriers it has faced for decades.

Improving Heart Failure Care for All, With Joshua Remick, MD

Joshua Remick, MD, a cardiologist with Providence Health & Services, joined 

 recently to moderate a clinical forum titled “Getting to the Heart of the Matter: Recognition to Treatment Optimization of Heart Failure.” In this post-forum interview, Remick breaks down the progress heart failure therapy has made in the past years, as well as highlighting where more momentum is needed.

“I think one of the things that we’ve learned most about heart failure management is that patients benefit the sooner they get on therapy and the quicker they get titrated up on appropriate therapies,” Remick told 

. “Because these therapies also impact other disease states like renal function, endocrine function, and cardiac care in general, these patients end up having interactions with multiple different specialties. The sooner all of these specialty providers feel comfortable getting patients on appropriate medical therapy, it’s going to benefit our patient population.”

Multidisciplinary care has been a cornerstone of cardiovascular care in recent years, given the rich interplay between the cardiovascular, endocrine, and other systems. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America released clinical guidelines explicitly recommending a multidisciplinary team, citing its capacity to reduce hospitalization rates and healthcare costs while improving self-care adherence and the use of guideline-directed medical therapy (GDMT).

The guidelines proposed a collaboration between cardiologists, surgeons, psychologists, immunologists, dieticians, clinical pharmacists, advanced practice providers, physical therapists, and more, aiming to address every possible facet of both immediate and long-term patient care. Remick expresses his support for this model.

However, despite these clear indications, heart failure treatment still faces lingering roadblocks. Among the most prevalent of these is the large-scale difficulty for both patients and clinicians in adopting and persisting with GDMT. Typical treatment begins with the simultaneous initiation of 4 medications, including beta-blockers, mineralocorticoid receptor agonists, SGLT2 inhibitors, and ARNIs or ACE inhibitors. Each drug addresses an individual component of heart failure risk, and as such, clinicians are advised to prescribe all 4 to a given patient.

However, several studies have highlighted the significant pill burden that this places on patients, particularly in situations when patients are unaware of the importance of quadruple therapy. Additionally, the financial burden posed by these 4 separate prescriptions is, in some situations, a substantial barrier to adherence – ARNIs and SGLT2 inhibitors in particular tend to rack up particularly burdensome costs.

In addressing this, Remick discussed the need for further patient education to drive home the importance of all 4 medications working in unison. He also acknowledged that, until action is taken on a large scale to shift all patients onto optimal GDMT, the negative outcomes that have positioned heart failure among the most fatal diseases in the US cannot significantly improve.

“A lot of times, we prescribe these drugs in patients who are doing quite well and living daily lives without major limitations and symptoms, so it’s a hard sell to try and get them to take more drugs, especially those that are associated with a fair amount of cost,” Remick said. “And so, especially in the US with the cost of healthcare, it’s really challenging to get all of that on board and get patients willing to do what’s needed.”

Editors’ Note: Remick reports no relevant disclosures.

Sokos G, KIDO K, PANJRATH G, et al. Multidisciplinary Care in heart failure services. 

Philbin SE, Gleason LP, Persell SD, et al. Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally Qualified Health Centers: A Thematic Qualitative Analysis. 

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Remick discusses multidisciplinary teams, adherence issues, and the path forward for heart failure care in this post-forum interview.

Joshua Remick, MD

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