Emerging Evidence to Guide Patient-Centric Treatment Selection for Heart Failure - Episode 14

Impact of Clinical Trials on Treatment of Heart Failure with Preserved Ejection Fraction (HFpEF)

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Experts in cardiology comment on the impact of recent trials on heart failure with preserved ejection fraction (HFpEF) in clinical practice.

James Januzzi, MD: I’m going to give Dr Butler a 10,000-foot-view question now. We’ve got results from PARAGLIDE-HF, we’ve got other contemporary trials. What do you think the impact on clinical practice is going to be for HFpEF [heat failure with preserved ejection fraction], specifically?

Javed Butler, MD, MPH, MBA: After 3 decades of nihilism that we can do nothing about HFpEF, that none of the trials are positive, things are really changing. Between the MRA [mineralocorticoid receptor antagonist] secondary analysis, ARNI [angiotensin receptor-neprilysin inhibitor] trials and SGLT-2 inhibitor trials, we now have several therapies we can give our patients with HFpEF. The thing that PARAGLIDE-HF really helps with is that, when new trials come out, and you see some subgroups here or there, people make a bit too much out of it and argue about it. For instance, with the SGLT-2 inhibitor, there was this whole thing about whether with higher ejection fraction there is benefit, and the second trial came out and that discussion ended. Here with PARAGON-HF, there was again this question that it was secondary analysis, and now PARAGLIDE-HF is so consistent that I think that question just goes away.[It determined] you should be using it in these patients. The second thing is that we have been emphasizing so much that these therapies should be started in the hospital setting, and now we have evidence of the benefit of starting it in the hospital setting. I think in that sense, it makes the implementation a whole lot easier.

James Januzzi, MD: So now we have evidence for in-hospital initiation. Regarding implementation, I’m going to turn to the co-director of the [Center for Cardiometabolic Implementation Science, at Brigham and Women’s Hospital] to ask him about implementation. What is the current state of the art with respect to heart failure therapy implementation? Let me give you a best case scenario. A patient is in the hospital, they’ve got HFpEF or HFrEF [heart failure with reduced ejection fraction], let’s be agnostic to the ejection fraction now. They’ve been started on either the 3 or 4 pillars, but they are at low doses, and they’re about to go home. What is the optimal state for their care at this point?

Muthiah Vaduganathan, MD, MPH: We’ve learned a wealth of information about optimal pathways for implementation over the last severalyears and turning that page from discovery science to implementation science. There are various tools now available to us, some embedded in the EHR [electronic health record], some based on multidisciplinary care teams, some based on post-discharge accelerated care models. I think in this patient who’s ready for discharge, first and foremost, again, [we need to be] arming that patient with education, a look forward of what’s to come. Then, rapid sequence optimization in the early outpatient period is going to be critical, not only to ensure that the patient continues to recover in that post-discharge window, but also to get the patient on target doses as studied in these pivotal randomized clinical trials.

Transcript edited for clarity