Josephine Harrington, MD

Panelists discuss how payers typically require step therapy with SGLT2 inhibitors before approving nonsteroidal MRAs due to cost considerations, while acknowledging the need for head-to-head trials to determine incremental benefits, though early clinical experience suggests good tolerability and the potential for combination therapy initiation rather than sequential treatment approaches.

Panelists discuss how nonsteroidal MRAs like finerenone differ mechanistically from steroidal MRAs by lacking steroid rings (reducing steroid-related adverse effects like gynecomastia), having different mineralocorticoid receptor binding patterns, shorter half-lives, and potentially lower hyperkalemia risk, with strong evidence supporting their use in heart failure with preserved ejection fraction and additive benefits when combined with SGLT2 inhibitors.

Panelists discuss how mineralocorticoid receptor antagonists (MRAs) remain underutilized despite being foundational therapy for heart failure with reduced ejection fraction due to clinician fears of hyperkalemia and renal dysfunction, while new nonsteroidal MRAs like finerenone show promise across the ejection fraction spectrum with potentially improved adverse effect profiles, though questions remain about their incremental benefit over traditional steroidal MRAs given their substantially higher cost.

Panelists discuss how GLP-1 receptor agonists show promising benefits for patients with HFpEF, particularly those with obesity-related disease, through significant weight loss and improved functional capacity, while their role in HFrEF remains more cautious due to concerns about increased heart rate and potential arrhythmic risks, though observational data suggest additive benefits when combined with SGLT2 inhibitors.

Panelists discuss how SGLT2 inhibitors evolved from diabetes medications to become foundational heart failure therapy with class I recommendations across the ejection fraction spectrum, providing cardiovascular and renal benefits through unclear but likely multiple mechanisms, with the elegant advantage of single-dose efficacy regardless of diabetes status or heart failure type.

Panelists discuss how ARNIs like sacubitril-valsartan provide superior outcomes compared with ACE inhibitors in HFrEF (20% reduction in cardiovascular events, 16% mortality reduction), with broad FDA approval across the ejection fraction spectrum and recent generic availability improving cost-effectiveness, though ACE inhibitors and ARBs remain viable second-line options when ARNI is not accessible.

Panelists discuss how diuretics serve as necessary “bailout therapy” for volume management in heart failure but should not substitute for guideline-directed medical therapy, with emerging evidence supporting more nuanced approaches to diuresis, including urinalysis monitoring and novel formulations like intranasal furosemide, while noting that effective heart failure therapies actually reduce diuretic requirements.

Panelists discuss how β-blockers remain foundational therapy for heart failure with reduced ejection fraction (using evidence-based agents like carvedilol, metoprolol succinate, or bisoprolol) with proven mortality benefits, while their role in heart failure with preserved ejection fraction is more questionable and potentially overused unless atrial fibrillation is present.

Panelists discuss how guideline-directed medical therapy has evolved to include 4-pillar treatment for heart failure with reduced ejection fraction (angiotensin-converting enzyme inhibitors/angiotensin receptor‐neprilysin inhibitors, β-blockers, mineralocorticoid receptor antagonists, SGLT2 inhibitors) that can reduce mortality by up to 60% and extend life by 6 years, though significant implementation gaps remain, with only about one-third of eligible patients receiving appropriate therapy, necessitating rapid initiation of all 4 drug classes within weeks rather than sequential titration.

Panelists discuss how effective heart failure management requires collaborative care across multiple specialties (primary care, cardiology, endocrinology, nephrology) with advanced practice providers serving as dedicated coordinators, utilizing multidisciplinary teams and algorithm-driven care protocols to optimize patient outcomes and prevent the hot potato approach to complex comorbidities.

Panelists discuss how heart failure classification involves HFrEF vs HFpEF distinctions and staging systems (A through D), with the greatest prevention opportunities existing in early stages A and B, where patients have risk factors or subclinical dysfunction but haven’t yet developed overt clinical symptoms.

Panelists discuss how quality metrics should focus on keeping patients out of hospitals through core medical therapies, measuring all-cause hospitalizations and days spent at home in the community, while tracking both process metrics (guideline-directed medical therapy prescriptions, comorbidity management) and outcome metrics (mortality, readmissions, quality of life) with financial incentives through Medicare Accountable Care Organization programs.

Panelists discuss how heart failure affects 1 in 4 people over their lifetime with 7 million current cases in the US, while Optum Health has implemented an innovative screening program using symptom questionnaires, BNP testing, and echocardiograms for patients over age 60 years during wellness visits.

Panelists discuss how heart failure creates a massive economic burden of approximately $30 billion annually (expected to reach $70 billion to $80 billion by 2030), driven by hospitalizations, readmissions, expensive multidrug regimens costing over $20,000 to $30,000 per patient, and high-cost interventions like ablations and advanced therapies.