Marat Fudim, MD

GLP-1 RAs in Heart Failure and Patient Monitoring, with Marat Fudim, MD

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prevalent and popular in the medical landscape. Recent studies, although limited in scope, have investigated the safety and efficacy of these treatments in 

, both with preserved ejection fraction (HFpEF) and with reduced ejection fraction (HFrEF). While some have noted the superiority of medications like semaglutide versus placebo for improving symptoms, others have encouraged caution, citing risks such as malnutrition and sarcopenia.

Marat Fudim, MD, associate professor of medicine and member of the Duke Clinical Research Institute at Duke University Medical Center, sat down with 

 to discuss the prevalence of GLP-1 RAs for heart failure, the importance of remote patient monitoring, and upcoming treatments on the horizon.

Fudim described his strategy for approaching weight loss therapies in patients with various 

“GLP-1 RAs, and weight loss therapies in general, are and always were phenotype-specific therapies, meaning you wouldn’t offer weight loss therapy to somebody who is normal or even low weight,” Fudim told 

. “So, by definition, unlike GDMT, it’s not a one-size-fits-all.”

Fudim explained his belief that GLP-1 RAs are better suited for patients with a body mass index (BMI) >27, particularly in patients with HFpEF. HFrEF treatment, however, should exhibit more caution. Fudim pushes for weight loss in patients with a BMI >35, although a BMI >30 in those with advanced stages of heart disease occasionally exhibits a protective factor.

Fudim also expressed his confidence in GLP-1 RAs, citing his own usage of them.

“I always make the point that I myself use GLP-1 RAs, and it worked great on me,” Fudim said. “I have a lot of experience with this drug; prescribing it, using it, so I think that having experience as a physician also helps in the description of side effects, counseling, and taking away some of the anxieties about these drugs.”

Pivoting to the ongoing discussion of remote monitoring, Fudim argued the value of the human and algorithmic aspect over the technological. Given the limitations presented by any one patient’s receptiveness to any one technology, Fudim points out the comparative importance of clinicians’ perspectives in remote care.

“I think that remote monitoring is indispensable, but I will be the first to tell you that it’s not always about technology,” Fudim said. “I mean, I have 10 technologies around that I could use tomorrow. Which one do you choose? Not every patient is receptive to something, not every patient is appropriate for something, not every insurance reimburses everything.”

Fudim also acknowledged the inherent limitations in constant monitoring, given the exponentially greater number of technologies than clinicians or assistants to monitor them consistently. He emphasized the necessity for further alignment with the human resource industry to more efficiently streamline remote care.

“I’m a big proponent of partnering with the industry – not the device industry, but actually the human resource industry to help us provide the resource, because my limitation is not the tech,” Fudin said. “My limitation is that I don’t have enough people to watch it. I have no time to watch it.”

Fudin also highlighted the growing awareness of the importance of phenotyping in heart failure treatment.

“I think we have slowly come to realize that, if we want to be successful in HFpEF, we just have to be a little more phenotype-specific in our therapy selection,” he said. “Match with the physiology, as opposed to HFrEF, where one size really fits all.”

In closing, Fudin discussed the potentially groundbreaking therapeutics on the horizon, particularly considering the limited landscape of HFpEF management. Given the significant side effect profile of most currently approved treatments, Fudin believes the heart failure landscape is in need of more accessible and well-tolerated medications.

“I can tell you that the landscape of heart failure trials is widening by the day, particularly for HFpEF,” Fudin told 

. “We have a very large variety of trials that are focusing on pre-capillary PH, post-capillary PH, gene-based therapies, device-based therapies. So, the space and time to be in right now is HFpEF; there’s a lot of opportunities.”

Editors' Note: Marat Fudim, MD, reports disclosures with Axon Therapies, Alleviant, CVRX, Impulse Dynamics, Abbott, and Endotronix.

Butler J, Shah SJ, Petrie MC, et al. Semaglutide versus placebo in people with obesity-related heart failure with preserved ejection fraction: a pooled analysis of the STEP-HFpEF and STEP-HFpEF DM randomised trials. Lancet. 2024;403(10437):1635-1648. 

Driggin E, Goyal P. Malnutrition and Sarcopenia as Reasons for Caution with GLP-1 Receptor Agonist Use in HFpEF. J Card Fail. 2024;30(4):610-612. 

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Fudim discusses his experiences in prescribing GLP-1 receptor agonists, as well as his opinions regarding remote patient monitoring.

Marat Fudim, MD

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