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 heart failure (HF) treatment.

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.1

“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 HCPLive 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 high blood pressure, high cholesterol, diabetes, atrial fibrillation, heart failure, heart attack, or stroke, was sent out to 2461 patients.1

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.1

Similarly, a 2022 study published in the Journal of Clinical Medicine 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.2

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.2

“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 HCPLive. “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.”

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

References

1. Shropshire SJ, Fabbri M, Manemann SM, et al. Patient awareness of heart failure diagnosis: A community study. JAHA. 2023;12(21). doi:10.1161/jaha.122.029284

2. 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. J Clin Med. 2022;12(1):99. Published 2022 Dec 22. doi:10.3390/jcm12010099