Optimizing Heart Failure Management - Episode 12
Dr Nasrien Ibrahim discusses the many factors that need to be considered when discussing medical adherence in both HFrEF and HFpEF, as well as improvements needed to help these patients.
James Januzzi, MD: Last section. We only have 10 minutes, so we’ve got to keep it tight, but this is I think so important for the audience because we have all these great data, and yet they are meaningless if we can’t implement therapies and foster adherence. Nasrien, you are a master clinician, someone who thinks a lot about this subject, and I really would love for you to share your thoughts about the issues that impact medication adherence in our patients with heart failure. We just say whether they have HFpEF [heart failure with preserved ejection fraction] or HFrEF [heart failure with reduced ejection fraction], it really doesn’t matter. What are the things that really affect adherence? And you’ve taught us a lot about how patients think in this area, so please share your thoughts.
Nasrien E. Ibrahim, MD: I would say even before adherence, I talk about inertia. And inertia can be clinician-related, patient-related, systems-related. It’s multifactorial, but I would say one of the first barriers is from clinicians. Either they’re overworked, or they’re not up to date because we haven’t done a great enough job of updating them on the quadruple therapy for HFpEF, or there’s this sense that, “My patients are doing fine. Why do I need to alter their medication regimen?” The patient inertia also comes from that sense of, “I feel fine. Why do you want to change my medication?” You always have to have this conversation that, “Maybe you feel now, but you’re not without risk of sudden cardiac death or hospitalizations down the line or worsening of your heart failure down the line.” Inertia becomes an issue. I would say access to heart failure cardiologists is also limited. A lot of patients are not seen by heart failure specialists. A lot of patients with heart failure are seen by general cardiologists and primary care physicians. Thus, we should make sure that we talk about the guidelines, talk about quadruple therapy, talk about ways that we’ve been able to get our patients on therapies. And I would say the discussion should always be shared between you and the patient.
What I do when I see patients is immediately tell them that they need to be on 4 classes of medications. They each work on a different pathway. They each have an additive benefit for reduction in mortality, so that you and the patient create a plan as to how you’re going to move forward to help that reluctant patient who says, “I feel fine.” I always talk about the need for speed, with Drs Butler and Fonarow being authors on, about this 42-day plan to get to target doses or maximum tolerated doses. We know we can’t be tone-deaf, there are financial barriers for some patients, and some carriers give pushback in terms of needing prior authorizations, despite medications being on guidelines. But I would say that when you get that pushback from insurance companies, it’s easy to write a letter, include the guidelines, and include the reasons why the patients should be on therapies. When finances become barriers, a lot of the pharmaceutical companies have patient-assistance programs. There are also other patient-assistance programs that are not connected to any institutions, that are not connected to any pharmaceutical industries.
But you need a multidisciplinary approach. Patient navigators can help with the paperwork because health literacy is also not uniform across our patients. You need to ask your pharmacist for help, social workers for help, but you really need to exhaust all options. I would say guideline-directed medical therapy optimization clinics would be fantastic if we could institute those in all institutions where patients come in, get their medications optimized and are sent on their way back to their general cardiologist or their primary care doctors. Or if patients need to be referred for mitral valve procedures or devices or advanced therapies, because they’re not improving, we can send them to those facilities. But we really need to work on creating satellite clinics, figuring out how to reach the most vulnerable populations that really don’t get seen by heart failure specialists, that have the highest morbidity and mortality. We need to find out how to infiltrate those areas and those neighborhoods with patients who have high mortality related to heart failure. Because sometimes these drugs are $0, sometimes they’re $4, but their benefit is enormous. Thus, we’re doing our patients a disadvantage by not getting out and getting to the patients who can’t necessarily reach us.
James Januzzi, MD: Yes. And this circles all the way back to what we talked about in the very beginning, which is getting our patients on optimal therapy so that we don’t miss the golden window of opportunity to get them in when their disease inevitably progresses. Patients who suffer from disparities in care frequently are the patients who when they miss their window, don’t get the benefit of the doubt for transplant or mechanical circulatory support, unfortunately. Thus, it’s one of those things where we really have to do our best to address the challenges in getting patients covered for their therapies. Often patients make that difficult trade-off of, “I have to buy groceries or get medication,” and that’s a trade-off that they should never have to make.
This transcript has been edited for clarity.