Improving Patient Education and Pill Burden in Heart Failure Treatment, With Anuradha Lala, MD

Although the overall nature of addressing heart failure (HF) in clinics has shifted to a more holistic approach, improvements can still be made to the patient’s side of treatment, including pill burden and patient education.

“Unfortunately, there’s a major gap between evidence and widespread, broad understanding,” Anuradha Lala, MD, professor of medicine, cardiology, and population health, director of the ACGME Fellowship in Advanced Heart Failure and Transplant, and Director of the Heart Failure Clinical Trials program at Mount Sinai Hospital, told HCPLive in an exclusive interview. “Despite patient behavior having an influence on outcomes, there are studies after studies that show that patients often leave a heart failure hospitalization without a clear understanding of what the disease is, why their medications matter, and what warning signs should prompt them to call us.”

HF is a product of several lifestyle factors including sleep, diet, exercise, and lipid levels. However, data from a past meta-analysis have shown that roughly 60% of premature deaths from HF could be attributed to unhealthy lifestyle factors. Additionally, roughly half of patients with HF do not follow recommended treatment procedures, limiting their chances of improvement.1

Prior research has emphasized the importance of informing patients of the potential risks of HF and how to manage them in their everyday life. A study from 2021, during which a proportion of patients were given 4-step education sessions to address misconceptions and potential lifestyle improvements, indicated increased capacity for self-management of risk factors afterwards. Patients who received education on their condition were more open to clinician suggestions for management.1

Another well-documented issue facing patients and clinicians alike is the pill burden present in HF treatment. The main medication cascade currently consists of 4 main drugs, known as the pillars of heart failure: angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA), and SGLT2 inhibitors. Standard GDMT recommends using all 4 treatments in every patient – given the sheer number of pills this requires, coupled with the disease’s implicit effects on quality of life, patients face a substantial burden simply from managing HF.2

“The average patient with heart failure with reduced ejection fraction is taking somewhere between 6 and 10 meds when you account for all their comorbid conditions or other risk factors like diabetes, hypertension, chronic kidney disease, depression, et cetera,” Lala said. “And then the 4 pillar GDMT on top of that is not trivial.”

Despite these limitations, the ongoing shift towards a more multidisciplinary means of treatment – including nephrology and endocrinology, among other specialties – is an encouraging step towards better HF care. Chief among this movement is the cardio-kidney-metabolic framework put forth by the American Heart Association in 2023, highlighting the interplay between cardiovascular health and major comorbidities like obesity or diabetes.

“I think that adopting this cardio-kidney-metabolic framework really emphasizes the various aspects of the disease,” Lala said. “It’s about underlying inflammation, altered physiology and hormone health, coupled with poor diet, lack of exercise, and so on, that leads ultimately to the manifestations of heart disease, heart failure being one of its most prominent forms. I think us shifting to understand that we need to treat patients holistically and not in our silos of expertise is huge, and I pray that patients will stand to do better from our more holistic standards of care.”

Editors’ Note: Lala reports disclosures with Abiomed, AstraZeneca, Merck & Co., Novo Nordisk, Sequana, Bayer, and others.

References

1. 1: Podvorica E, Bekteshi T, Oruqi M, Kalo I. Education of the Patients Living with Heart Disease. Mater Sociomed. 2021;33(1):10-15. doi:10.5455/msm.2021.33.10-15

2. 2: Smith JL, Killian JM, Shippee N, et al. Burden of treatment in patients with heart failure. Journal of the American Heart Association. 2025;14(10). doi:10.1161/jaha.124.039695