Expert Perspectives on the Updated ACC Decision Pathway for Optimization of Heart Failure Treatment - Episode 3

Heart Failure Treatment in the Healthcare System

James Januzzi, MD, Massachusetts General Hospital, Harvard Medical School

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Javed Butler, MD, MPH, MBA, University of Mississippi Medical Center

A look into the role of heart failure treatment in health care and the overall provision of optimal medical therapy.

James Januzzi, MD: Of course, the million-dollar question now is how are we doing with respect to heart failure treatment? Why would we think about the need for an expert consensus decision pathway document for optimal medical management for the diagnosis?

Javed Butler, MD, MPH, MBA: Unfortunately, we are not doing as well as we could be. If you think about it, a provision of good health care is a 2-front war. One front is doing research, science, and generating evidence to know how to treat the patients well. The other is implementing that. We have done remarkably well over the past 3 decades on the first front. We have a lot of therapies—drug-based therapies, device-based therapies—and we know that these therapies change the natural history and trajectory of the disease. They can make you live longer and healthier. We have devices as well, but we have not done a very good job in implementing these. Implementation is tough. There are a lot of issues: health care, insurance, and tolerability issues. But if you look at the overall provision of optimal medical therapy, the rates are so low that all of these other factors cannot explain those trends. We clearly need to do better on the second part.

James Januzzi, MD: Yes. For example, the work that you’ve done with the CHAMP-HF registry is really eye-opening, with several thousand patients with heart failure and a reduced ejection fraction identified in practices across North America. These are American institutions delivering health care. What was perhaps the most striking aspect of the result from the CHAMP-HF study to me is that there were 3 major classes of drug therapies at the time. Now there are 4, and we’re going to talk about that in just a few minutes. If you looked at the 3 major classes of drugs for heart failure with reduced EF [ejection fraction] at that time, only 1% of the patients in CHAMP-HF were on all 3 drugs, and with all 3 drugs at the target dose. That is a stunning statistic. We all fancy ourselves to be excellent clinicians who understand how to initiate and titrate these therapies, but the simple reality is that there’s a clear gap in adherence in everyday practice, as you pointed out. As you say, we have the drugs, but there’s a real need in understanding how to optimally implement them. That’s why the American College of Cardiology created the expert consensus decision pathway documents to help meet that unmet need.

Transcript Edited for Clarity