The Gap to Fill: Rationale for Rapid Initiation and Optimal Titration of Comprehensive Disease-modifying Medical Therapy for Heart Failure with Reduced Ejection Fraction

In-hospital initiation of sodium-glucose cotransporter-2 inhibitors in patients with heart failure and reduced ejection fraction: 90-day prescription patterns and clinical implications

INTRODUCTION

Safety and early clinical benefit make sodium-glucose cotransporter-2 inhibitor (SGLT2-i) therapy suitable for in-hospital initiation in patients with heart failure and reduced ejection fraction (HFrEF). Despite randomized controlled trials and guideline recommendations, they are underused, and clinical inertia may play a role.

OBJECTIVES PRIMARY

To assess the impact of initiating SGLT-2i at discharge on 90-day prescription rates in patients with HFrEF during hospitalization for acute heart failure (AHF). Secondary: To evaluate the presence of independent factors associated with prescription, and to explore clinical outcomes at 90 days.

METHODS

Retrospective analysis of a consecutive prospective single-center cohort. Adult patients hospitalized between January 2021 and September 2022 with a primary diagnosis of AHF and left ventricular ejection fraction (LVEF) <40% were included. The primary outcome was SGLT2-i prescription rate at 90 days, and the exploratory secondary endpoints was the composite of hospitalization or urgent visit for AHF or all-cause mortality at 90 days.

RESULTS

237 patients were included. Mean age was 76±11 years, and mean LVEF was 29±7%. In patients without contraindications, SGLT2 inhibitors (SGLT2-i) were prescribed during hospitalization in 52.3%. At 90 days, the SGLT2-i prescription rate was 94.2% in those with in-hospital initiation and 14.4% in those without. (p<0.001). Independent factor associated with inpatient prescription was lower LVEF, 0.83 (95% CI: 0.77-0.89) for each point. Patients with in-hospital SGLT2-i initiation showed a lower rate of the combined endpoint of all-cause death, HF rehospitalization, or unplanned HF visit at 90 days (44.4% versus 23.9%, p=0.005).

CONCLUSIONS

In-hospital initiation of SGLT-2-i was associated with significantly higher prescription rates and lower prevalence in the secondary combined endpoint at 90 days. This study reflects the presence of medical inertia, particularly in patients with higher LVEF, and highlights the hospitalization period as an optimal time to start SGLT2-i.

Implementation of guideline-directed medical therapy for heart failure patients with reduced ejection fraction in Belgium: a Delphi panel approach

BACKGROUND

The 2021 European Society of Cardiology (ESC) guidelines recommended a shift from a traditional hierarchical treatment for heart failure with reduced ejection fraction (HFrEF) to a four-pillar medical therapy strategy intended for near-simultaneous initiation. However, practical guidance for implementation in clinical practice is lacking. To address this, a Delphi Panel of 12 Belgian heart failure experts aimed to obtain consensus on integrating guideline-directed medical therapy (GDMT) in HFrEF patients in Belgian clinical practice, considering local specificities, including reimbursement criteria.

METHODS

A geographically representative sample of 12 Belgian cardiologists engaged in a three-round Delphi process, evolving from 20 open-ended questions to 39 statements. A qualitative analysis after the first round resulted in expert statements for the subsequent questionnaire, categorised into treatment for newly diagnosed and chronic HFrEF patients.

RESULTS

The Delphi consensus revealed four key findings: (i) Agreement on initiating the four medical cornerstones within 7-14 days of HFrEF diagnosis, prioritising initiation over individual class up-titration; (ii) Lack of consensus on a fixed sequence for initiation due to patient variability and national reimbursement criteria; (iii) Emphasis on treatment adjustment based on the patient's clinical presentation and comorbidities; (iv) Recognition of the crucial role of regular follow-up visits, allowing optimisation of medical therapy where appropriate.

CONCLUSION

This national Delphi consensus addresses clinical implementation of GDMT in HFrEF patients for Belgian cardiologists. The consensus highlights the importance of swift implementation of the four cornerstone medical therapies in newly diagnosed HFrEF patients, individualising treatment sequencing, and ensuring regular follow-up to optimise therapy.

A pharmacist-led heart failure stewardship initiative for guideline-directed medical therapy in hospitalized patients with reduced ejection fraction

Background

Heart failure with reduced ejection fraction (HFrEF) is a progressive disease with high rates of hospitalization and mortality. The Canadian Cardiovascular Society recommends treating patients with HFrEF with medications from 4 standard medication classes-this is known as guideline-directed medical therapy (GDMT). However, despite clear evidence and recommendations, GDMT agents are known to be underutilized in the HFrEF population.

Objective

To determine if the implementation of a prescriber-alert stewardship tool for hospitalized patients with HFrEF will increase the frequency of GDMT prescribing with all classes during hospitalization.

Methods

Utilization of GDMT in patients with HFrEF between admission and discharge pre- and post-implementation of a prescriber alert stewardship tool was compared. Patients admitted to a cardiology stepdown unit between January and April 2022 had a stewardship-alert tool placed on their chart for physician review, while those admitted during the same time frame 1 year prior did not.

Results

Following the use of a prescriber alert, there was a statistically significant increase in prescribing for β-blockers (38.1% to 95.2%; p < 0.001), mineralocorticoid receptor antagonists (9.5% to 66.7%; p < 0.001) and combination GDMT (9.5% to 52.4%; p = 0.004) from admission to discharge. A statistically significant increase in the prescribing of β-blockers (47.6% to 76.2%; p = 0.004) and angiotensin-converting enzyme inhibitors (21.4% to 40.5%; p = 0.008) was still observed without the use of the prescriber alert.

Conclusion

A pharmacist-led heart failure stewardship tool initiative increased uptake of GDMT in patients with HFrEF.

Ischemic Stroke and Reduced Left Ventricular Ejection Fraction: A Multidisciplinary Approach to Optimize Brain and Cardiac Health

Reduced left ventricular ejection fraction ≤40%, a known risk factor for adverse cardiac outcomes and recurrent acute ischemic stroke, may be detected during an acute ischemic stroke hospitalization. A multidisciplinary care paradigm informed by neurology and cardiology expertise may facilitate the timely implementation of an array of proven heart failure-specific therapies and procedures in a nuanced manner to optimize brain and cardiac health.

Development and Optimization of the Veterans Affairs' National Heart Failure Dashboard for Population Health Management

BACKGROUND

In 2020, the Veterans Affairs (VA) health care system deployed a heart failure (HF) dashboard for use nationally. The initial version was notably imprecise and unreliable for the identification of HF subtypes. We describe the development and subsequent optimization of the VA national HF dashboard.

MATERIALS AND METHODS

This study describes the stepwise process for improving the accuracy of the VA national HF dashboard, including defining the initial dashboard, improving case definitions, using natural language processing for patient identification, and incorporating an imaging-quality hierarchy model. Optimization further included evaluating whether to require concurrent ICD-codes for inclusion in the dashboard and assessing various imaging modalities for patient characterization.

RESULTS

Through multiple rounds of optimization, the dashboard accuracy (defined as the proportion of true results to the total population) was improved from 54.1% to 89.2% for the identification of HF with reduced ejection fraction (HFrEF) and from 53.9% to 88.0% for the identification of HF with preserved ejection fraction (HFpEF). To align with current guidelines, HF with mildly reduced ejection fraction (HFmrEF) was added to the dashboard output with 88.0% accuracy.

CONCLUSIONS

The inclusion of an imaging-quality hierarchy model and natural-language processing algorithm improved the accuracy of the VA national HF dashboard. The revised dashboard informatics algorithm has higher use rates and improved reliability for the health management of the population.

Heart failure management guidelines: New recommendations and implementation

The prevalence of heart failure has increased in many developed countries including Japan and the USA, due in large part to the aging of their populations. The lifetime risk of heart failure is now 20-30 % in the USA. Fortunately, there have been important advances in therapy that increase quality and length of life for those with heart failure. This review discusses the important advances in care including treatment and diagnosis and the new recommendations for this care from the recent American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) Guideline. Relevant studies that have been published since the guideline was released are also included. Of the many recommendations in the ACC/AHA/HFSA Guideline, this review focuses on the definition of heart failure, the medical treatments specific to left ventricular ejection fraction, use of devices for treatment and diagnosis, diagnosis and treatment of amyloidosis, treatment of iron deficiency, screening for asymptomatic left ventricular dysfunction, use of patient reported outcomes, and tools for implementation.

Evaluation of vital signs through a mobile application in patients with heart failure: a opportunity for remote titration?

BACKGROUND

Virtual consultations have increased exponentially, but a limitation is the inability to assess vital signs (VS). This is particularly useful in patients with heart failure (HF) for titrating prognosis-modifying medication. This issue could potentially be addressed by a tool capable of measuring blood pressure (BP) and heart rate (HR) accurately, remotely, and conveniently. Mobile phones equipped with transdermal optical imaging technology could meet these requirements.

OBJECTIVE

To evaluate the accuracy of a transdermal optical imaging-based app for estimating VS compared to clinical assessment in patients with HF.

METHODS

A prospective cohort study included patients evaluated in an HF outpatient unit between February and April 2022. BP and HR were simultaneously assessed using the app and clinical examination (BP with an automated sphygmomanometer and HR by brachial palpation). Three measurements were taken by both the app and clinic for each patient, by two independent blinded physicians.

RESULTS

Thirty patients were included, with 540 measurements of BP and HR. The mean age was 66 (± 13) years, 53.3% were male. The mean left ventricular ejection fraction was 37 ± 15, with 63.3% having previous hospitalizations for HF, and 63.4% in NYHA class II-III. The mean difference between the app measurement and its clinical reference measurement was 3.6 ± 0.5 mmHg for systolic BP (SBP), 0.9 ± -0.2 mmHg for diastolic BP (DBP), and 0.2 ± 0.4 bpm for HR. When averaging the paired mean differences for each patient, the mean across the 30 patients was 2 ± 6 mmHg for SBP, -0.14 ± 4.6 mmHg for DBP, and 0.23 ± 4 bpm for HR.

CONCLUSION

The estimation of BP and HR by an app with transdermal optical imaging technology was comparable to non-invasive measurement in patients with HF and met the precision criteria for BP measurement in this preliminary study. The use of this new transdermal optical imaging technology provides promising data, which should be corroborated in larger cohorts.

Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial

BACKGROUND AND AIMS

Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF.

METHODS

Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge.

RESULTS

Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT.

CONCLUSIONS

A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.

Economic Evaluations of Guideline-Directed Medical Therapies for Heart Failure With Reduced Ejection Fraction: A Systematic Review

OBJECTIVES

Decision-analytic models (DAMs) with varying structures and assumptions have been applied in economic evaluations (EEs) to assist decision making for heart failure with reduced ejection fraction (HFrEF) therapeutics. This systematic review aimed to summarize and critically appraise the EEs of guideline-directed medical therapies (GDMTs) for HFrEF.

METHODS

A systematic search of English articles and gray literature, published from January 2010, was performed on databases including MEDLINE, Embase, Scopus, NHSEED, health technology assessment, Cochrane Library, etc. The included studies were EEs with DAMs that compared the costs and outcomes of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin-receptor neprilysin inhibitors, beta-blockers, mineralocorticoid-receptor agonists, and sodium-glucose cotransporter-2 inhibitors. The study quality was evaluated using the Bias in Economic Evaluation (ECOBIAS) 2015 checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklists.

RESULTS

A total of 59 EEs were included. Markov model, with a lifetime horizon and a monthly cycle length, was most commonly used in evaluating GDMTs for HFrEF. Most EEs conducted in the high-income countries demonstrated that novel GDMTs for HFrEF were cost-effective compared with the standard of care, with the standardized median incremental cost-effectiveness ratio (ICER) of $21 361/quality-adjusted life-year. The key factors influencing ICERs and study conclusions included model structures, input parameters, clinical heterogeneity, and country-specific willingness-to-pay threshold.

CONCLUSIONS

Novel GDMTs were cost-effective compared with the standard of care. Given the heterogeneity of the DAMs and ICERs, alongside variations in willingness-to-pay thresholds across countries, there is a need to conduct country-specific EEs, particularly in low- and middle-income countries, using model structures that are coherent with the local decision context.

Differential Impact of Systolic and Diastolic Heart Failure on In-Hospital Treatment, Outcomes, and Cost of Patients Admitted for Pneumonia

Background

Patients admitted with pneumonia and heart failure (HF) have increased mortality and cost compared to those without HF, but it is not known whether outcomes differ between systolic and diastolic HF. Management of concomitant pneumonia and HF is complicated because HF treatments can worsen complications of pneumonia.

Methods

This is a retrospective cohort study from the Premier Database among patients admitted with pneumonia between 2010-2015. Patients were categorized based on systolic, diastolic, and combined HF using ICD-9 codes. The primary outcome was in-hospital mortality. Secondary outcomes included use of HF medications, length of stay, cost, intensive care unit (ICU) admission, as well as use of invasive mechanical ventilation (IMV), vasopressors and inotropes. Multivariable logistic regression was used to describe associations of these outcomes with type of HF.

Results

Of 123,211 patients with pneumonia and HF, 41,196 (33.4%) had systolic HF, 69,982 (56.8%) diastolic HF, and 12,033 (9.8%) had combined HF. Compared to patients with diastolic HF, after multivariable adjustment systolic HF was associated with higher in-hospital mortality (OR 1.15; 95% CI:1.11-1.20), ICU admission, and use of IMV and vasoactive agents, but not with increased length of stay or cost. Among patients with systolic HF, 80% received a loop diuretic, 72% a beta blocker, 48% angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and 12.5% a mineralocorticoid receptor antagonist.

Conclusion

Systolic HF is associated with added risk in pneumonia compared to diastolic HF. There may also be an opportunity to optimize medications in systolic HF prior to discharge.

Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction

Guideline-directed medical therapy (GDMT) is the cornerstone of pharmacological therapy for patients with heart failure with reduced ejection fraction (HFrEF) and consists of the four main drug classes: renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors and sodium glucose cotransporter 2 inhibitors. The recommendation for use of GDMT is based on the results of multiple major randomized controlled trials demonstrating improved clinical outcomes in patients with HFrEF who are maintained on this therapy. The effect is most beneficial when medications from the four main drug classes are used in conjunction. Despite this, there is an underutilization of GDMT, partially due to lack of awareness of how to safely and effectively initiate and titrate these medications. In this review article, we describe the different drug classes included in GDMT and offer an approach to initiation and effective titration in both the inpatient as well as outpatient setting.

Optimizing outcomes in heart failure: 2022 and beyond

Although the development of therapies and tools for the improved management of heart failure (HF) continues apace, day-to-day management in clinical practice is often far from ideal. A Cardiovascular Round Table workshop was convened by the European Society of Cardiology (ESC) to identify barriers to the optimal implementation of therapies and guidelines and to consider mitigation strategies to improve patient outcomes in the future. Key challenges identified included the complexity of HF itself and its treatment, financial constraints and the perception of HF treatments as costly, failure to meet the needs of patients, suboptimal outpatient management, and the fragmented nature of healthcare systems. It was discussed that ongoing initiatives may help to address some of these barriers, such as changes incorporated into the 2021 ESC HF guideline, ESC Heart Failure Association quality indicators, quality improvement registries (e.g. EuroHeart), new ESC guidelines for patients, and the universal definition of HF. Additional priority action points discussed to promote further improvements included revised definitions of HF 'phenotypes' based on trial data, the development of implementation strategies, improved affordability, greater regulator/payer involvement, increased patient education, further development of patient-reported outcomes, better incorporation of guidelines into primary care systems, and targeted education for primary care practitioners. Finally, it was concluded that overarching changes are needed to improve current HF care models, such as the development of a standardized pathway, with a common adaptable digital backbone, decision-making support, and data integration, to ensure that the model 'learns' as the management of HF continues to evolve.

Optimization of Patient Pathway in Heart Failure with Reduced Ejection Fraction and Worsening Heart Failure. Role of Vericiguat

Heart failure (HF) is a progressive condition with periods of apparent stability and repeated worsening HF events. Over time, unless optimization of HF treatment, worsening HF events become more frequent and patients enter into a cycle of recurrent events with high morbidity and mortality. In patients with HF there is an activation of deleterious neurohormonal pathways, such as the renin angiotensin aldosterone system and the sympathetic system, and an inhibition of protective pathways, including natriuretic peptides and guanylate cyclase. Therefore, HF burden can be reduced only through a holistic approach that targets all neurohormonal systems. In this context, vericiguat may play a key role, as it is the only HF drug that activates the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate system. On the other hand, it has been described relevant disparities in the management of HF population. Consequently, it is necessary to homogenize the management of these patients, through an integrated patient-care pathway that should be adapted at the local level. In this context, the development of new technologies (ie, video call, specific platforms, remote control devices, etc.) may be very helpful. In this manuscript, a multidisciplinary group of experts analyzed the current evidence and shared their own experience to provide some recommendations about the therapeutic optimization of patients with recent worsening HF, with a particular focus on vericiguat, and also about how the integrated patient-care pathway should be performed.

Insights into foundational therapies for heart failure with reduced ejection fraction

In this review, we discuss what is meant by "foundational" therapy for patients with heart failure and reduced ejection fraction (HFrEF) and the evidence supporting the use of the five agents that comprise this group of drugs i.e., sacubitril/valsartan, a beta-blocker, an aldosterone or mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter 2 (SGLT2) inhibitor. We review the conventional approach to sequencing these therapies in HFrEF and proposed new rapid sequencing strategies. We review a recent modelling study suggesting the optimal sequence of treatment includes a sodium-glucose cotransporter 2 inhibition and an MRA as the first two therapies. Finally, we review the important opportunity offered by hospitalization for worsening heart failure to initiate and optimize foundational therapies in patients at high risk of early adverse outcomes.

Sodium-Glucose Co-transporter-2 Inhibitors in Heart Failure with Preserved Ejection Fraction: A Breakthrough in Improvement of Clinical Outcomes?

The conventional conception of the therapy of heart failure (HF) with reduced ejection fraction has been recently modified by adding sodium-glucose co-transporter-2 (SGLT2) inhibitors to the combination consisting of beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors, with the aim of improving clinical outcomes. It remains unclear whether other sub-populations of patients with HF, having either HF with preserved ejection fraction (HFpEF) or HF with mildly reduced ejection fraction, are relevant candidates for the effective therapeutic intervention that includes SGLT2 inhibitors. The purpose of the narrative review is to elucidate plausible perspectives for the clinical implementation of SGLT2 inhibitors into optimal medical therapy in patients with HFpEF. The authors searched the bibliographic databases (Embase, Medline, and the Web of Science) and the Cochrane Central to find English-written publications satisfying the purpose of this study. The authors included eight studies and two meta-analyses that have been reported as completed and found that there were high heterogeneous data regarding the fact that SGLT2 inhibitors had strict resemblance in their efficacy among patients with HFpEF with and without Type 2 diabetes. Due to the use of unpublished data and findings from the trials ended early, there is a lack of upper left ventricular ejection fraction threshold levels to identify inclusion criteria and no agreement in heart failure with reduced ejection fraction determination. However, the results of the meta-analysis, especially come from subgroups’ analysis, appeared to be relevantly optimistic for use of SGLT2 inhibitors in HFpEF therapy.

Vericiguat in Heart Failure with a Reduced Ejection Fraction: Patient Selection and Special Considerations

With improvement in the understanding of the pathophysiological mechanisms of heart failure with reduced ejection fraction (HFrEF), several drug classes have been developed targeting the renin–angiotensin–aldosterone system, the beta adrenergic system, and to a certain extent the nitric oxide pathway. Recently, the use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors has resulted in a reduction in heart failure hospitalizations and cardiovascular death. As a result, SGLT-2 inhibitors are now the fourth drug class recommended as part of guideline-directed medical therapy (GDMT) for HFrEF. Soluble guanylate cyclase (sGC) stimulators, such as vericiguat, are a novel therapy targeting the cyclic guanosine monophosphate (cGMP) pathway with downstream effects including smooth muscle cell relaxation and a reduction in hypertrophy, inflammation, and fibrosis. The recently published VICTORIA trial has demonstrated a reduction in heart failure hospitalizations or cardiovascular death with vericiguat. Patients with a baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) values <8000 pg/mL may identify a sub-group most likely to benefit with addition of vericiguat. The cumulative benefit of quadruple therapy with the addition of sGC stimulators remains unknown. We review the mechanism of action for sGC stimulators, clinical trial data, and their real-world application to HFrEF patients with consideration of quintuple therapy.

In-hospital Initiation and Up-titration of Guideline-directed Medical Therapies for Heart Failure with Reduced Ejection Fraction

Implementation of guideline-directed medical therapy for patients with heart failure is suboptimal. The use of guideline-directed medical therapy improves minimally after heart failure hospitalisation, despite this event clearly indicating increased risk of further hospitalisation and death. In-hospital initiation and titration of guideline-directed medical therapies is one potential strategy to fill these gaps in care, both in the acute vulnerable period after hospital discharge and in the long term. The purpose of this article is to review the knowledge gaps in best practices of in-hospital initiation and up-titration of guideline-directed medical therapies, the benefits and risks of in-hospital initiation and post-discharge focused titration of guideline-directed medical therapies, the recent literature evaluating these practices, and propose strategies to apply these principles to the care of patients with heart failure with reduced ejection fraction.