Key opinion leaders provide an overview of the treatment gaps in the management of heart failure.
John McMurray, MBChB: Although I said that we have had many successes in the treatment of heart failure with reduced ejection fraction, there is still a huge unmet need in heart failure. That is especially so in patients with heart failure and preserved ejection fraction [HFpEF] or preserved and midrange ejection fraction because, at the moment, we have no approved therapy for those patients. We treat them empirically to relieve congestion. We treat their comorbidities, but we’ve got nothing that has been clearly demonstrated to reduce hospital admission or improve survival.
Even though we have been successful in heart failure with reduced ejection fraction, these patients still have a tremendously high mortality rate. They still are frequently admitted to the hospital, and there is always room for further improvement.
Scott D. Solomon, MD: The major gaps in care are the patients who are not getting all the things I just talked about. We [at Brigham and Women’s Hospital] recently published some data in The Lancet saying that if patients receive many of these disease-modifying therapies, such as beta-blockers, mineralocorticoid receptor antagonists, sacubitril-valsartan, and an SGLT2 inhibitor, they would have about a 60% reduction in their overall risk of having a future heart failure, hospitalization, or dying. They could benefit in terms of extra years of life: up to 8 years.
The first thing we have to do is make sure patients are on the medications that have been proven to be beneficial for heart failure with reduced ejection fraction. In HFpEF, we don’t have that because we don’t yet have definitive therapies that have been proven to reduce morbidity and mortality. However, we’ve come close with both spironolactone in the TOPCAT trial and sacubitril-valsartan in the PARAGON-HF trial. In addition, we have to remember that patients with heart failure are extremely vulnerable. One of the therapies I proselytize about is making sure that all my patients with heart failure get their annual flu shots. You’d think that this would be something they would all do because the influenza vaccination is recommended in all people over 6 to 8 months of age, but you’d be surprised how many patients with heart failure don’t get vaccinated for flu. About 52% of people in the United States get the flu vaccine, and maybe 50% to 60% of patients with heart failure get vaccinated. We’ve got to do better than that because when patients with heart failure have other problems, like influenza, they’re at markedly higher risk. Unfortunately, this is also true right now with COVID-19 [coronavirus disease 2019]. Heart failure patients who get COVID-19 have a much higher risk of dying than patients without heart failure.
Jaime Murillo, MD: The gaps in care you’re asking about in health care today are, No. 1, what I just alluded to, which is the fact that we don’t have a specifically tailored therapy for a specific type of heart failure. Let’s take the reduced ejection fraction heart failure or the heart failure with preserved ejection fraction as an example. Even within those 2 large groups, we still have significant subgroups.
We have those who have hypertensive heart disease, those who have ischemic heart disease, those who have valvular-related disease or even atrial fibrillation–related heart failure, those who have underlying chronic kidney disease, those who have amyloidosis, and those who have cardiomyopathies. Hypertensive cardiomyopathies is an area in which we have not done enough, especially in certain minority patients. That’s the other gap: We have not approached minority patients for heart failure. I’m referring specifically to the African American population with underlying hypertensive disease prone to developing dilated cardiomyopathy, not necessarily ischemic heart disease but a nonischemic type of cardiomyopathy. That’s a group for whom we have an opportunity.
Another gap is that we’re not necessarily treating the underlying cause appropriately. This would be for the patient who has the classic example of preserved heart failure: the older woman with a small heart, dilated atria, and some underlying atrial fibrillation who doesn’t know much about diet, and she is eating pizza. Those filling pressures in the lungs are going up overnight, and they end up in the hospital. That’s a group for whom we don’t have the luxury of waiting 2 or 3 days for them to be compensated. They can decompensate very quickly. We must tailor the therapy, address the patients, and address the social determinants of health, such as where they have an opportunity to get their medications and whether they’re being compliant with their medications.
Another huge opportunity is utilizing nonclinicians or nontraditional clinicians, such as pharmacists, to ensure medication adherence. We could also use social workers to look at living conditions. There is a recent trend in utilizing community health workers. These are peers who are trained to utilize some protocol-based approach with the disease to provide support, counseling, and education to other community members who have the same condition but don’t know much about it. That’s an interesting approach that still needs to be assessed in more detail, but it’s worth considering significantly.
Another huge gap is that the health care industry has reached the level of other industries. I’m going to specifically compare it with banking. When was the last time you went to a bank? It’s been awhile, right? You still complete all your transactions. I’m not necessarily saying that health care is the same as the banking industry, but we have a lot to learn from other industries. We cannot depend on our patients receiving care only when they come to the office or they happen to be in the emergency department of a hospital. We need to give them access, which may be a digital opportunity to create a virtual environment where they have access to care: They have the opportunity to ask questions, and they have the opportunity to receive notifications and alarms that say, “We noticed that this is happening with you, so please do this, and make those adjustments.” This would connect with the provider so that the provider can take action on a timely basis; that’s a huge opportunity. The digital part of that is another major opportunity.
I’m going to mention another one. I could go on and on, but let me just talk about cardiac rehabilitation. For decades, it has been underutilized. It is simple, it is cost effective, and it has better outcomes, lower readmissions, and even improved mortality, which is amazing. The beauty is that it works even better for younger patients, achieving a rate of 3.3% for patients to be more likely to quit smoking. We also realize that it makes people more likely to have blood pressure control and cholesterol control. Cardiac rehabilitation is another big opportunity for heart failure patients. I can tell you this: In our health plan, only 2% of heart failure patients utilize cardiac rehabilitation. That is dismal, 2%.
What we [at United Health Care] have done is probably something that not many people know about. For 2021, we are going to 0 co-pay for Medicare patients because we believe in trying to eliminate some barriers that will prevent people from attending cardiac rehabilitation. This is 1 approach, and I’m hoping that over time CMS [Centers for Medicare & Medicaid Services] will also recognize the value of home health care and specifically home-based cardiac rehabilitation. We’re working on that process by lobbying the CMS and developing pilots where we can test the value of home health care.