Expert Perspectives on the Updated ACC Decision Pathway for Optimization of Heart Failure Treatment - Episode 12

Challenges for Achieving Optimal Therapy in HF

April 30, 2021
James Januzzi, MD, Massachusetts General Hospital, Harvard Medical School

Javed Butler, MD, MPH, MBA, University of Mississippi Medical Center

Cardiology experts discuss challenges in achieving the optimal therapy for patients with heart failure and the influence of patient lifestyle and medical factors.

James Januzzi, MD: Javed, we have a few more minutes. I wanted to get to some more philosophical, but very important topics that we touch on in the expert consensus document. One is the challenges of achieving optimal therapy in our more complicated cases, especially given the multiple drugs that we need to prescribe. For example, how do you approach an elderly patient? Does that differ from your general therapeutic approach?

Javed Butler, MD, MPH, MBA: The word elderly means a lot of things. The first and foremost thing I would say is that elderly means bias on our part as clinicians. There’s bias that somebody may not tolerate or benefit from a therapy. At least the benefit part has been taken off. We have never done a trial where we have given a therapy to an older person and they did not benefit. We have been doing that since the hypertension days where we thought that poor people have higher blood pressure, and that should be part of the physiology, and that’s not true. It’s the same thing with heart failure. When we do the secondary analysis, older patients benefit. We should definitely be treating these patients.

The issue of safety is real. Blood pressure, renal function, and all of these physiologic parameters that change with age are common traits. Some people may require the separation of times they take medications so that they’re not all at the same time. Maybe give a break of a couple of hours, take something at 8 in the morning and something at 11 in the morning so that not all the drugs are lowering the blood pressure at the same time. Go through the list of medications that they’re taking. If they’re taking a medication that does not play a role in improving morbidity or mortality, stop that medication. These people are taking a lot of medications. I would also say that if somebody is taking nitrates or amlodipine for no reason, we as clinicians know to stop those things. But then the patient takes so many over-the-counter things that we don’t even know what the hemodynamic effects are. Talking to the patients about all these nutraceuticals and whatnot. If you can stop those things, that becomes pretty important in older patients, as well.

Then there are social things: their hearing deficit, self-efficacy, whether they can take care of themselves, who’s the caregiver, whether they need home health, and social work. All of those things play into that. The last thing is that older people tend to have multiple comorbidities, so they tend to see multiple clinicians. You don’t want to have 1 set of clinicians doing 1 thing and the other set of clinicians doing something else. Communicating between the health care teams is also very important.

James Januzzi, MD: Yes, that’s critically important and very useful advice. Adherence—a term that we used to call compliance, but we recognize that adherence speaks to a larger set of issues other than just the decision not to take a medication—to a therapy can be influenced by so many physiologic and social aspects of care. All need to be kept in mind. Working as a heart team in heart failure, including our colleagues who are specialists in other disease states, such as our kidney specialists and geriatricians, is so very important. Additionally, costs of care are something that we address in the expert consensus decision pathway document. This is obviously an increasing issue in modern medicine, particularly in the United States. We offer advice on how to manage the costs of care in order to reduce the burden on our patients. That’s an important factor that is built into the concept of adherence.

Transcript Edited for Clarity