Heart Failure With Reduced Ejection Fraction: A Q&A With Dr James Januzzi
Heart failure (HF) is a serious, complex condition that affects an estimated 5.7 million adults in the United States, according to the Centers for Disease Control and Prevention (CDC).1
The risk for and severity of HF is influenced by factors including obesity; smoking; a high intake of fat, sodium, and cholesterol; and insufficient physical activity. Depending on the severity of one’s condition, patients with HF can often have a poor prognosis. In fact, nearly half of people with HF die within 5 years of diagnosis.1
The prognosis and treatment of HF can be complicated by a variety of factors such as age, race/ethnicity, and comorbidities, said James L. Januzzi Jr, MD, who is the Hutter Family Professor of Medicine at Harvard Medical School in Boston, Massachusetts, and Chair of the American College of Cardiology (ACC) Task Force on Expert Consensus Decision Pathways.
Consultant360 recently spoke with Dr Januzzi specifically about the treatment of HF with reduced ejection fraction (HFrEF), as well as barriers that may arise when treating patients with the condition. Dr Januzzi is also a member of the ACC’s Heart Failure Pathway Writing Committee, which recently published the “2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction.”2
Consultant360: In terms of appropriate care and treatment, how does HFrEF differ from HF with preserved ejection fraction (HFpEF) or borderline ejection fraction? What are some important things to consider in treating this patient population?
James Januzzi: In terms of appropriate treatment, HFrEF fundamentally differs from HFpEF in that HFrEF has several proven therapies that reduce morbidity and mortality, whereas we are still searching for a set of therapies for HFpEF that achieve this goal. Patients with borderline ejection fraction (HFbEF) remain an ambiguous population that does not yet have considerations in the guidelines with respect to drug therapies.
C360: What comorbidities are common with HF, and how do they complicate treatment?
JJ: Chronic kidney disease (CKD), atrial fibrillation (AF), and chronic lung disease are common in patients with HF. HF patients who are also treated for CKD are more likely to experience high potassium levels and interactions with therapies. Patients with AF are often less responsive to beta blockers (ß-blockers) and have lower blood pressure, and patients with chronic lung disease are sometimes intolerant to ß-blockers at the doses we need to use in those with heart failure.
C360: Is there a standard of care for patients with HFrEF, or does treatment often vary among certain groups of patients, such as older patients and African American patients?
JJ: Although there is a standard of guideline-directed medical therapy (which is more or less the same across all patients with reduced ejection fraction), how these medications are delivered differs, however, depending on the patient. Some patients, such as the elderly, require a more gradual titration and may ultimately receive lower doses due to side effects of other dose-limiting issues. Patients with kidney troubles may not be able to receive certain medications because of interactions with their renal problems.
African Americans are an important consideration. Black patients may respond somewhat differently to certain heart failure medications, most notably hydralazine/isosorbide. However, as we articulated in the ACC Expert Consensus Pathway Document on Heart Failure with Reduced Ejection Fraction, first-line therapies for people of color remain quite similar to non–African-Americans, though ambiguity exists as to whether sacubitril/valsartan (a new drug that is now Class I for treatment of patients with reduced ejection fraction heart failure) is similarly effective in blacks. More data are coming in that regard. Regardless, for now, in the absence of clinical data, we must use good clinical judgment.
C360: What are some barriers or challenges that practitioners may encounter in treating HFrEF? What strategies do you use to overcome them in your own practice?
JJ: It may be challenging for clinicians to remember the appropriate sequence of therapies to select for affected patients; the pharmacopeia of heart failure treatment is complex at times, and it’s important to emphasize unlike other disease states that heart failure therapy is dosed to the maximum tolerated (or “goal”) doses. Achieving goal dosing of guideline-directed medical therapies is frequently challenging, requiring arduous adjustment. However, it’s quite clear that patients achieving such treatment targets do better than those who do not. In the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment document, we provide important information regarding starting doses, strategies for titration, and re-iterate again and again how important it is to achieve target doses. A smart phone application supporting the document is pending release, which will help to really guide clinicians.
Beyond the factors regarding how to apply and titrate therapies to goal, it’s important to remember there is a patient in the equation. There may be challenges regarding ability to apply and intensify therapies in certain populations. Those with heart failure are frequently affected by other medical conditions that make it challenging to titrate therapies. For example, older patients pose a particular challenge. As HF is a diagnosis of the elderly, this is not insignificant. Older patients with heart failure tend to have lower blood pressure, which may limit their tolerance to titration of therapies. They may have more side effects to treatment as well. To avoid such issues, it's important to concede that older patients may not hit the goal doses of therapies the way younger patients might. Slower, more gradual titration is frequently needed.
Importance of compliance with diet, lifestyle, and medication program is an important discussion to have with patients. Strategies to improve compliance with these may help to overcome these challenges. Costs of care are an important consideration and in the 2017 ACC Expert Consensus Pathway document we address this topic, providing advice regarding how to mitigate the costs of care as best as possible.
C360: How does the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment help address these barriers, and what do practitioners need to know before using it in practice?
JJ: We provide useful information regarding starting doses and target doses of established and emerging HF therapies. We suggest a strategy for titration for therapies, and offer useful guidance regarding "what to expect" when adjusting therapies. In addition, we discuss the common barriers to achieving target doses of treatments and suggest mitigation strategies that clinicians might find helpful to overcome the obstacles to achieving guideline-directed medical therapy for their patients with HF.
This document includes important information regarding how to know when it's time to refer your patient to an advanced HF specialist. We discuss barriers to achieving optimal therapy, including how to improve patient compliance and assist in dealing with costs of care. We also discuss the all-important subject of where palliative care/hospice fits in. Of course, the core of the document focuses on guideline-directed medical therapy and how to achieve it. I’m very excited about the development of a smartphone application that will help guide therapy choices and how to apply and titrate them.
The decision pathway is based on the most recent guideline statements for HF, so clinicians should not hesitate to put the pathway into practice. We have made it practical and user-friendly. In addition, there will be a smartphone-based application coming soon that will help guide clinicians through optimal strategies to reach guideline-compliant care.
For the full version of the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment, click here.
—Christina Vogt
References:
1. Heart failure fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm. Updated June 16, 2016. Accessed on January 9, 2018.
2. Yancy CW, Januzzi Jr JL, Allen LA, et al; Heart Failure Pathway Writing Committee. 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction [Published online December 22, 2017]. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2017.11.025.