New Therapies in

Heart Failure
Management

Nagendra S Chouhan
MD, DNB, FNB, FAPSIC, FACC, FSCAI
Director Interventional Cardiology
Medanta The Medicity
Gurgaon, India
Heart Failure Outcomes in
Indian Patients with HFrEF

CAD accounts for Underlying T2DM is ≈1 in 5 cases die

≈3/4th of cases of present in ≈1 in 2 within 90-days post
HFrEF.1,2 cases of HFrEF.1,2 hospital-discharge
(19.5%, THFR).2

At hospital- 72% lower risk of 90-

≈1 in 3 cases die
discharge, only 1/4th day mortality, with
within 1-year (INTER-
of patients receive GDMT at hospital-
CHF, THFR).3,4
GDMT (THFR).2 discharge (THFR).2
1. Chopra VK et al. Indian Heart J. May-Jun 2019;71(3):242-8.
2. Ganapathi S et al. J Card Fail. 2018 December; 24(12):842-8.
3. Harikrishnan S, Sanjay G, Anees T, et al. Eur J Heart Fail. 2015 Aug;17(8):794-800.
4. Dokainish M, Teo K, Zhu J, et al. Lancet Glob Health. 2017 Jul;5(7):e665-e672.
 Empagliflozin

Eplerenone Dapagliflozin
 EXPANDING HORIZON OF HEART FAILURE
MANAGEMENT

Option for end

Disease Interventional
EP devices stage heart
Modifying Drugs Devices
failure

B Blockers
Mitra clip
CRT
LV assist devices
ACEI/ ARB HOT CRT
Cardioband,
Neochord
MRA
Paravalvular leak
closure
ARNI
ICD Heart transplant

LV aneurysm repair
SGLT2 Inhibitors
 Heart failure with reduced ejection fraction (HFrEF) requires a multimodal
treatment with combination of several drugs as the cornerstone
for symptomatic and prognostic improvement in all patients
ACEI β-blocker MRA ARB IVA ICD ARNI SGLT-2I
Reduction in relative risk of
mortality vs placebo

16% 17% 17%

(4.5% ARR; mean
follow up of 41.4
(3.0% ARR; median
follow-up of 33.7 months) 19% 20%
months) DAPA HF
SOLVD-T 1,2 CHARM-
30% Alternative5 SHIFT6 31%
PARADIGM HF
34% (11.0% ARR; mean
follow up of 24
EMPEROR REDUCE
(5.5% ARR; mean
follow up
months) MEDIT
of 1.3 years) RALES4
CIBIS-II3

Mortality in HFrEF remains high despite the introduction of therapies over the
last 20 years that improve survival

~50% of patients die within 5 years of diagnosis7-9

1. McMurray et al. Eur Heart J 2012;33:1787–847; 2. SOLVD Investigators. N Engl J Med 1991;325:293–302; 3. CIBIS-II Investigators. Lancet 1999;353:9–13; 4. Pitt et al. N Engl J Med 1999;341:709-17;–50; 5. Granger et al. Lancet
2003;362:772–6; 6. Swedberg K, et al. Lancet. 2010 Sep 11;376(9744):875-85. 7. Go et al. Circulation 2014;129:e28-e292; 8. Yancy et al. Circulation 2013;128:e240–327; 9. Levy et al. N Engl J Med 2002;347:1397–402
Disease-Modifying Pharmacological Therapy for HEF-RF

B Blocker +
ARNI/ ACEI SGLT2- I MRA
Ivabradine
• Sacubitril/Va • Carvedilol • Empagliflozi • Eplerenone
lsartan  • Metoprolol n • Aldactone
• Bisoprolol • Dapagliflozin
• Ivabradine

Adjustment of therapies ---Every 2 weeks

To achieve optimal GDMT within 3 to 6 months of an initial diagnosis of HF

Frequent reassessment of the clinical status, BP, and kidney function (and electrolytes) should be performed

Reassessment of ventricular function-- Should occur 3 to 6 months after target (or maximally tolerated) doses of GDMT
are achieved to determine the need for device therapies such as ICD /CRT
 Early Comprehensive disease-modifying pharmacological therapy

patients without
contraindications
appear to gain most
benefit from
combined treatment
with the ‘fantastic
four’
European Heart Journal (2021) 42, 681–683 EDITORIAL
doi:10.1093/eurheartj/ehaa101
 CV Death or HHF Outcomes in Patients with HFrEF
Absolute Risk Reduction (ARR) and Number Needed to Treat (NNT)
Direct comparison of studies should be interpreted with caution due to differences in study design, populations and methodology
% o f Patien ts w ith even t

CV Death or HHF (Incidence, % of patients)

ARR: 5.3% 40 ARR: 4.8% 40 ARR: 4.7%
NNT: 19 Control Treatment
NNT: 21 NNT: 22
40 (16 months) (18 months) (27 months)
30 30

30 26.5
24.7 20 20
20.9 21.8
20 19.4
16.1
10 10
10

0
EMPEROR REDUCED DAPA HF PARADIGM HF
1. Packer M et al. NEJM. 2020 Aug 29; DOI: 10.1056/NEJMoa2022190
2. McMurray JJV et al. 2019 Sept 19; DOI: 10.1056/NEJMoa1911303
3. McMurray JJV et al. 2014; DOI: 10.1056/NEJMoa1409077
The
Foundational
Four
Therapies in
HFrEF

A Patient-Centric
Re-appraisal of
Approach to
HFrEF

1.Adapted: Packer M, McMurray JJV. Eur J Heart Fail. 2021 Mar 11. doi: 10.1002/ejhf.2149.
2.Adapted: McMurray JJV, Packer M. Circulation. 2021 Mar 2;143(9):875-7.
 Compelling proof of robust risk-reduction for HHF and
death: BB, SGLT2-i, ARNi, MRA.1,2

Each foundational therapy is effective, independently of

Foundationa others:

l Therapies • Each acts through distinct patho-physiological mechanisms. 1,2

• Decisions about optimum sequencing should not depend on historical

for HFrEF discovery, but on therapeutic advantages, tolerability, ease-of-use. 1,2

Clinical benefits occur rapidly, following initiation of each

foundational therapy.1,2

Need for Introducing additional foundational drug: More benefit

than up-titrating existing drug.1,2
Rapid
Early initiation of 4 foundational therapies in 4 weeks,
Sequencing facilitates early risk-reduction.1,2

In optimum sequencing, some foundational drugs can

improve safety-profiles of others.1,2
1.Adapted: Packer M, McMurray JJV. Eur J Heart Fail. 2021 Mar 11. doi: 10.1002/ejhf.2149.
2.Adapted: McMurray JJV, Packer M. Circulation. 2021 Mar 2;143(9):875-7.
 Rapid
Sequencing
Algorithm,
For Introducing
Foundational
Therapies in
HFrEF

•1.Adapted: Packer M, McMurray JJV. Eur J Heart Fail. 2021 Mar 11. doi: 10.1002/ejhf.2149.
•2.Adapted: McMurray JJV, Packer M. Circulation. 2021 Mar 2;143(9):875-7.
Step 1.
Simultaneous Initiation of Beta-Blocker + SGLT2-inhibitor1,2

Beta-blockade:
• Most effective and rapidly-acting option to prevent sudden cardiac death.
• Most likely to benefit left-ventricular remodeling, in long-term treatment.
• May cause fluid-retention and early worsening of HF.

SGLT2-inhibition:
• Early osmotic diuresis; rapid reduction in risk of HF worsening.
• Kidney protection, by slowing the annual rate of decline in kidney function.
• Does not require specialized safety monitoring, or laboratory testing.
• Initiated at therapeutic dose, without requiring dose-titration.

1.Adapted: Packer M, McMurray JJV. Eur J Heart Fail. 2021 Mar 11. doi: 10.1002/ejhf.2149.
2.Adapted: McMurray JJV, Packer M. Circulation. 2021 Mar 2;143(9):875-7.
Step 2.
Introduction of ARNi1,2

ARNi enhances effect of

Reduces risk of mortality,
Rapid and profound effect to RAS-i; reduces associated
additive survival benefit to
lower natriuretic peptides. risk of worsening kidney
beta-blockade.
function.

Symptomatic hypotension Simultaneous initiation of

possible; minimized by using If pretreatment SBP <100 ARNi and MRA avoided in
low-doses with slow up- mmHg, preferable to initiate patients without prior use of
titration, and/or by reducing ARB and establish RAS-i: Risk of worsening
dose of concomitant tolerability kidney function, and
diuretics. hyperkalemia.

1.Adapted: Packer M, McMurray JJV. Eur J Heart Fail. 2021 Mar 11. doi: 10.1002/ejhf.2149.
2.Adapted: McMurray JJV, Packer M. Circulation. 2021 Mar 2;143(9):875-7.
Step 3.
Introduction of MRA1,2
Significant reductions in morbidity and mortality in HFrEF.

Ease of use in once-daily dosing, minimal uptitration, and modest effect on BP.

MRA can worsen kidney function, and cause hyperkalemia.

Background use of SGLT2-i and ARNi may lower risk or worsening kidney function
and hyperkalemia; increase likelihood of long-term persistence on MRA.
1.Adapted: Packer M, McMurray JJV. Eur J Heart Fail. 2021 Mar 11. doi: 10.1002/ejhf.2149.
2.Adapted: McMurray JJV, Packer M. Circulation. 2021 Mar 2;143(9):875-7.
Fantastic Four - DATA
• EMPHASIS HF DAPA HF EMPEROR-Reduced
• Paradigm HF • 10.7% on • 19.5% on
Sacubitril/Valsartan Sacubitril/Valsartan
• DAPA HF
• EMPEROR-Reduced
Increase in Survival with Foundational-Four versus
Conventional Therapy Options in Patients with HFrEF
Conventional Therapy:
β-blocker + RAS-i

Foundational Four:
β-blocker + SGLT2-i + ARNi + MRA

Additional ↑ in Life-Expectancy with

Foundational Four vs. Conventional Therapy:
• At 55 years: 6.3 yrs (95% CI 3.4 to 9.1 yrs)
• At 65 years: 4.4 yrs (95% CI 2.5 to 6.2 yrs)
• At 80 years: 1.4 yrs (95% CI 0.8 to 1.9 yrs)

Treatment difference between Foundational Four and Conventional Therapy:

Solid Line: Mean Difference; Shaded Outer Area: 95% Confidence Intervals Vaduganathan M et al. Lancet 2020; 396: 121-28.
Advances in heart failure management

Para Valvular Leak

Mitral Valve in Valve

Mitra Clip
84 yrs man
Post cabg Post DVR , severe PARA valvular leak
Recurrent LVF, Surgical risk -34%
Heart Team – Minimally invasive is the future

• Post MVR post AVR

• Severe Paravelvular MR
• Percutaneous procedure failed

• With help of surgeons – Trans

apical approach
• 3D TEE Guidence
• Successful closure of leak

Key hole surgery

Case : Mitral Valve in Valve
• 82 yrs CKD, DM, RHD, COPD
• Post DVR 10 yrs back
• Severe LV Dysfunction
• Post ICD
• Acute LVF
• ECHO
– Mitral BioPHV Dysfunction – Severe valvular
MR Mean PG – 15 mmhg
– PASP = 70 mmHg
– Aortic PHV Mean Gr -18 mmHg

– STS score – 51% in hospital mortality

– Extreme Surgical Risk
Case –
Wire in IVC, Percutaneous Ecmo System
primed

Mitral Valve In Valve

Procedure
• Percutaneous Through
Femoral Venous Access
• Trans-septal approach
• Iatrogenic ASD
• Sapien S3 = 26 size
• ASD closed with device
Discharged on Day 5, Nyha Class II
Discharged on Day 5, Nyha Class II
67 year old male shortness of breath NYHA III

• LVEF = 38%
• LV size = 8 cm
• Mild Tricuspid
regurgitation
• Moderate RV
dysfunction
• Mild MV disease
Percutaneous MV Repair by Mitra Clip
Baseline TEE
First clip deployment
Post second clip procedure
 Using Disease modifying drugs has revolutionized heart
failure therapy
• Fantastic four: Start early start together

Percutaneous valve repair and replacement – Game

changing inventions
• Mitra clip can reduce heart failure deaths and improve quality of life
• Paravalvular leak after surgery can be treated without redo surgery

Physiological pacing in HF: CRT, HOT CRT - Opened a new

horizon

Take Home
 Contact::
Dr. Nagendra S. Chouhan
9971382999 MD, DNB, FNB, FAPSIC, FSCAI, FACC
Director - Interventional Cardiology

chouhan.ns@gmail.com Medanta The Medicity, Gurgaon

 KEY TAKE AWAYS:
Questions answered
Switching ACEI to ARNI in symptomatic patient is safe and easy and helps in Reducing Mortality and
Morbidity

Switching from ACEI to ARNI adds years to life as well as improves quality of life

There should be gap of 36 hours between last ACEI dose and initiation of ARNI.

If blood pressure is on lower side start ARNI at smaller doses and decrease dose of diuretics.

Monitor serum potassium and Creatinine levels.

Sacubitril/Valsartan was found to improve LVEF and multiple measures of reverse remodeling above
and beyond the effect of pre-existing OMT.
Thank You Dr. Nagendra S. Chouhan
MD, DNB, FNB, FAPSIC, FSCAI, FACC
Ass. Director - Interventional Cardiology
Medanta The Medicity
Gurgaon

Contact:
9971382999
Chouhan.ns@gmail.com
Introduction
• HF --- Escalating Rapidly

• Consumes substantial
healthcare resources

• Inflicts considerable morbidity

and mortality

• Greatly affects quality of life .

 10 Pivotal Pathway Summary
How to implement GDMT ... How to address challenges with ... How to manage ...

Issue 1. Initiate, Add, or Switch Issue 3. Referral Issue 8. Increasing Complexity

2017 ACCF/AHA Heart Failure Guidelines

Treatment algorithm for GDMT Triggers for referral to HF specialist 12 pathophysiological targets
including novel therapies Issue 4. Care Coordination in HFrEF and treatments .
Essential skills for an HF team 11 principles and actions to
Issue 2. Titration Infrastructure for team-based HF guide optimal therapy
Target doses, indications, care
contraindications, and other Issue 9. Comorbidities
considerations of select GDMT for Issue 5. Adherence Common cardiovascular and
HFrEF Considerations for monitoring Causes of nonadherence Non cardiovascular comorbidities
Considerations to improve with suggested actions
adherence
Issue 6. Specific Patient Cohorts Issue 10. Palliative/ Hospice Care
Evidence-based recommendations Seven principles and actions to
and assessment of risk for special consider regarding palliative care
cohorts: older adults, and the frail
Issue 7. Medication Cost and Access
Strategies to reduce patients’ cost of
care .

GDMT = guideline-directed medical therapy; HF= heart failure; HFrEF = heart failure with reduced ejection fraction
Initiating GDMT for HFrEF 2021
• Established Therapies---ARNIs, ACEIs, ARBs ,BB, Loop Diuretics, MRAs, HYD/ISDN
• Excepting Loop Diuretics all improve symptoms, reduce hospitalizations, and/or
prolong survival .

• ARNIs are the preferred, but for patients in whom ARNI administration is not
possible, an ACEI/ARB is recommended.

• Use of digoxin as a treatment for HFrEF lacks new data current role- as a rate
control agent for AF in those with low BP.
• Initiation of a beta-blocker is better tolerated when patients are dry and an
ACEI/ARB/ARNI when patients are wet. Only evidence-based beta-blockers should
be used.
 HFrEF Stage C Trt Light Green color - Class I therapy
Light yellow color Class II
Treatment Algorithm For therapy.
*ACEl/ARB should
GDMT Including Novel only be considered in
Therapies patients with
ARNI/ACEI/ARB* contraindications,
(ARNI preferred; AND intolerance or
evidence-based BB # with
inaccessibility to
diuretic agent as needed
ARNI. #Carvedilol,
metoprolol succinate,
or bisoprolol.

For patients with For patients For patients For persistently For patients with
eGFR ≥:30 symptomatic Black resting HR ≥ 70,
ml/min/1.73 m2 meeting eGFR with
criteria , persistent patients despite on maximally
or creatinine
≤2.5 mg/dl in males ARNI/BB/MRA tolerated BB
NYHA class II- volume /SGLT2 inhibitor, dose in
or ≤ 2.0 mg/dl
in females or IV overload, NYHA class III-IV sinus rhythm,
K+ ≤ 5.O mEq/L NYHA class II-IV NYHA class II-III
NYHA Class ll·IV

Add Add Titrate Add Add

SGLT2I HDN Ivabra

MRAs Diuretic
+ISDN dine
Treatment Algorithm For A B C
GDMT Including Novel
Therapies Evidence-based
ARNI
ACEI/ARB BB

If previously on ACEI, ensure 36 hours off Select initial dose of beta-

before initiation blocker:
SELECT STARING DOSE 24/26 mg–49/51 mg twice Consider in patients
daily ;MAINTENACE DOSE 97/103 mg twice daily where ARNI
administration is not Consider increasing dose of BB
possible
every 2 weeks until maximum
If patient is taking If patient is taking tolerated or target dose
equivalent of ≤10 mg equivalent of >10 mg is achieved
daily of enalapril daily of enalapril or Select initial dose of
or equivalent of ≤ 160 equivalent of >160 mg
Monitor HR, BP, and for signs of
mg of valsartan: ACEI or ARB: congestion after initiation and
daily of valsartan: 49/51 mg twice daily during titration
24/26 mg twice daily

In 2 weeks, assess tolerability

If possible, increase dose stepwise to target of 97/103 mg twice daily
Monitor blood pressure, electrolytes, and renal function after initiation and
during titration
 D E F
Treatment Algorithm For
GDMT Including Novel
Therapies Aldosterone
Diuretics SGLT2 inhibitor
antagonists

Select initial loop diuretic dose: Select initial dose of Select dapagliflozin or
Initial dose depends on multiple factors, aldosterone empagliflozin: 10MG/day
including renal function and prior exposure to antagonist:
diuretic therapy

Titrate dose to relief of congestion over days to Consider increasing dose

weeks. In some instances it may be necessary to of aldosterone antagonist
reduce diuretic dosing in the setting of increasing at least every 2 weeks
doses of ARNI/ACEI/ARB until maximum tolerated Ensure eGFR ≥30 ml/min/1.73
or target dose is achieved m2
Monitor BP , electrolytes, and renal function after Monitor electrolytes for dapagliflozin and eGFR
initiation and during titration (especially potassium) ≥ 20 ml/min/1.73 m2 for
and renal function at 2-3 empagliflozin before initiation
days following initiation,
If reaching high doses of loop diuretic (i.e.,
and then 7 days after
equivalent of 80 mg of furosemide twice daily),
initiation/titration
consider: a. changing to a different loop diuretic
Then, check monthly for 3
Or b. adding thiazide diuretic, taken together with
months and every 3
loop diuretic Monitor BP, electrolytes, and renal
months afterwards
function after initiation and during titration
Treatment Algorithm For
G
GDMT Including Novel
Therapies
Hydralazine + isosorbide
dinitrate

Select initial dose of hydralazine and

isosorbide dinitrate, either as individual
medications or fixed-dose combination:

Consider increasing dose of hydralazine

and/or isosorbide dinitrate every 2 weeks
until maximum tolerated or target dose
is achieved .Monitor blood pressure after
initiation and during titration
Treatment Algorithm For H
GDMT Including Novel
Therapies Ivabradine

Reassess that BB are adjusted to maximally tolerated doses and/or

target doses Verify patient is in sinus rhythm

Select starting dose of ivabradine:

Age ≥ 75 years : 2.5 mg twice daily with food Age < 75 years : 5 mg twice daily with food

Reassess heart rate in at least 2-4 weeks

Heart rate <50 beats/min or Heart rate Heart rate

symptoms of bradycardia 50-60 beats/min >60 beats/min

Reduce dose by 2.5 mg twice Maintain current Increase by 2.5 mg twice

daily with food or dose and monitor daily with food until
discontinue if already at 2.5 heart rate reaching maximum dose of
mg twice daily with 7 .5 mg twice daily with
Food Monitor heart rate food Monitor heart rate
Summary for Initiation and Titration of HFrEF Therapies
Adjustment of therapies ---Every 2 weeks.

Aim -To achieve optimal GDMT within 3 to 6 months of an initial diagnosis of HF.

Follow-up---Frequent reassessment of the clinical status of the patient, BP, and kidney
function (and electrolytes) should be performed.

Reassessment of ventricular function-- Should occur 3 to 6 months after target (or

maximally tolerated) doses of GDMT are achieved to determine the need for device
therapies such as ICD /CRT .

HIGH risk for sudden death --The time to follow-up imaging might be shorter (e.g., 3
months), whereas in those at lower risk, time to follow-up might be longer (e.g., 6 months)
Angiotensin Receptor-Neprilysin Inhibitor (ARNI)-----
PREFERRED ?
Indications for Use of an ARNI--- HFrEF (EF <=40%) NYHA class II–IV HF

Administered in conjunction with a background of GDMT for HF in place of an ACEI / ARB(If

previously on ACEI …Ensure 36 hrs. off before initiation) . Lack of treatment with an MRA should not
delay initiating or switching a patient to an ARNI.

Demonstrated improvement in ECHO parameters of reverse cardiac remodeling as early as 12

weeks( independent of background therapy with ACEIs/ARBs ).

Associated with improvement in diastolic function, left ventricular

function, quality of life, and burden of ventricular arrhythmias-
(PARADIGM-HF , PROVE-HF , EVALUATE-HF)
Angiotensin Receptor-Neprilysin Inhibitor (ARNI)- issue ?
The initiation of ARNI in hospitalized ADHF pts feasible after the patient has been
hemodynamically stabilized and not volume –depleted

In patients with Borderline blood pressure (e.g., SBP <=100 mm Hg), careful administration
and follow-up are advised.

Renal function and potassium should be checked within 1-2 weeks of initiation or dose up-
titration of ACEI/ARB/ARNI.

In non congested patients with otherwise stable clinical profiles, empiric modest lowering
of loop diuretic agents has been found to mitigate the hypotensive effects of
sacubitril/valsartan.
TABLE --- Indications for ARNI, Ivabradine, and SGLT2 Inhibitor Use
Indications for Use of an ARNI
 HFrEF (EF ≤ 40%)
 NYHA class II–IV HF
 Administered in conjunction with a background of GDMT for HF in place of an ACEI
or ARB

Indications for Use of Ivabradine

 HFrEF (EF ≤ 35%)
 On maximum tolerated dose of beta-blocker
 Sinus rhythm with a resting heart rate ≥ 70 beats/min
 NYHA class II or III HF

Indications for Use of an SGLT2 Inhibitor

 HFrEF (EF ≤ 40%) with or without diabetes
 NYHA class II–IV HF
 Administered in conjunction with a background of GDMT for HF
Severe Mitral Regurgitation and the Use of Transcatheter
M V Repair

GDMT has to optimized before referral for the procedure to ensure

the greatest likelihood that patients will receive the combined
benefits of optimal GDMT together with edge-to-edge repair.

Surgical treatment is recommended in cases of severe primary

chronic MR resulting in HFrEF
Patients in Whom New Therapies May Not Be Indicated

When life expectancy is short (<1 year) due to other

comorbidities, implantable devices may not be appropriate.

NYHA class IV and Stage D HF being considered for advanced

therapies may not be appropriate
 Starting and Target Doses of Select GDMT and Novel Therapies for HF
Starting Dose Target Dose
Beta-Blockers
Bisoprolol 1.25 mg once daily 10 mg once daily
Carvedilol 3.125 mg twice daily 25 mg twice daily for weight ≤85 kg and
50 mg twice daily for weight ≥85kg
Metoprolol succinate 12.5–25 mg daily 200 mg daily
ARNIs
Sacubitril/valsartan 24/26 mg–49/51 mg twice daily 97/103 mg twice daily
ACEIs
Captopril 6.25 mg 3x daily 50 mg 3x daily
Enalapril 2.5 mg twice daily 10–20 mg twice daily
Lisinopril 2.5–5 mg daily 20–40 mg daily
Ramipril 1.25 mg daily 10 mg daily
ARBs
Candesartan 4–8 mg daily 32 mg daily
Losartan 25–50 mg daily 150 mg daily
Valsartan 40 mg twice daily 160 mg twice daily
Aldosterone antagonists
Eplerenone 25 mg daily 50 mg daily
Spironolactone 12.5–25 mg daily 25–50 mg daily
SGLT2 inhibitors
Dapagliflozin 10 mg daily 10 mg daily
Empagliflozin 10 mg daily 10 mg daily
 CONTD Starting and Target Doses of Select GDMT and Novel Therapies for HF
Starting Dose Target Dose
Vasodilators
Hydralazine 25 mg 3 x daily 75 mg 3 x daily

Isosorbide dinitrate† 20 mg 3 x daily 40 mg 3 x daily

Fixed-dose combination isosorbide 20 mg/37.5 mg (1 tab) 3 x 2 tabs 3 x daily

dinitrate/hydralazine‡ daily
Ivabradine
Ivabradine 2.5–5 mg twice daily Titrate to heart rate 50–60
beats/min. Maximum dose 7.5
mg twice daily

*Use of digoxin as a treatment for HFrEF lacks new data ( current role- as a rate control agent for AF in those with low BP )
†Isosorbide mononitrate is not recommended by the ACC/AHA/HFSA guideline.
‡The ACC/AHA/HFSA guideline considers either the fixed-dose combination or the separate combination of isosorbide dinitrate and hydralazine as appropriate
guideline-directed therapy for HF.
 TABLE Dose Adjustments of Sacubitril/Valsartan for Specific Patient Populations
Population Initial Dose
High-dose ACEI 49/51 mg
> Enalapril 10-mg total daily dose or therapeutically twice daily
equivalent dose of another ACEI
High-dose ARB
> Valsartan 160-mg total daily dose or
therapeutically equivalent dose of another ARB
De novo initiation of ARNI 24/26 mg twice daily
Low- or medium-dose ACEI
≤ Enalapril 10-mg total daily dose or therapeutically
equivalent dose of another ACEI
Low- or medium-dose ARB
≤ Valsartan 160-mg total daily dose or
therapeutically equivalent dose of another ARB
ACEI/ARB naïve
Severe renal impairment*
(eGFR <30 mL/min/1.73 m2)
Moderate hepatic impairment (Child-Pugh Class B)
Elderly (age ≥75 years)

*This population was not studied in the PARADIGM-HF trial. The statement is consistent with FDA-approved labeling indications.
PARADIGM-HF = Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in HF.
TABLE Recommended Starting Dose of Ivabradine

Population Initial Dose

Maximally tolerated beta-blocker dose 5 mg twice daily with meals

with persistent resting heart rate ≥70
beats/min

History of conduction defects 2.5 mg twice daily with meals

Age ≥ 75 years
TABLE Contraindications and Cautions for Sacubitril/Valsartan,
A) Sacubitril/Valsartan
Contraindications Cautions
 Within 36 hours of ACEI use  Renal impairment:
 History of angioedema with or without an ACEI or ARB • Mild-to-moderate (eGFR 30-59 mL/ min/1.73 m2): no
 Pregnancy starting dose adjustment required
 Lactation (no data) • Severe (eGFR <30 mL/min/ 1.73 m2): reduce starting dose
 Severe hepatic impairment (Child-Pugh C) to 24/26 mg twice daily; double the dose
 Concomitant aliskiren use in patients with diabetes • every 2–4 weeks to target maintenance dose of 97/103 mg
 Known hypersensitivity to either ARBs or ARNIs twice daily, as tolerated
 Hepatic impairment:
• Mild (Child-Pugh A): no starting dose adjustment required
• Moderate (Child-Pugh B): reduce starting dose to 24/26 mg
twice daily; double the dose every 2–4
• weeks to target maintenance dose of 97/103 mg twice daily,
as tolerated
 Renal artery stenosis
 SBP <100 mm Hg
 Volume depletion
TABLE Contraindications and Cautions for Ivabradine
B) Ivabradine
Contraindications Cautions
 HFpEF  Sinus node disease
 Presence of angina with normal EF  Cardiac conduction defects
 Hypersensitivity  Prolonged QT interval
 Severe hepatic impairment (Child-Pugh
C)
 Acute decompensated HF
 Blood pressure <90/50 mm Hg
 Sick sinus syndrome without a
pacemaker
 SA node block
 2nd or 3rd degree block without a
pacemaker
 Resting HR <60 beats/min
 Persistent AF or flutter
 Atrial pacemaker dependence
TABLE Contraindications and Cautions for SGLT2 inhibitors
C) SGLT2 Inhibitors
Contraindications Cautions
 Not approved in T1DM due to  For HF care, dapagliflozin, eGFR <30 mL/min/1.73 m2
increased risk of diabetic  For HF care, empagliflozin, eGFR <20 mL/min/1.73 m2
ketoacidosis  Pregnancy
 Known hypersensitivity to  Increased risk of mycotic genital infections
drug  May contribute to volume depletion. Consider altering diuretic dose if applicable
 Lactation (no data)  Ketoacidosis in patients with diabetes:
 On dialysis • Temporary discontinuation before scheduled surgery is recommended to avoid potential risk
for ketoacidosis
• Assess patients who present with signs and symptoms of metabolic acidosis for ketoacidosis,
regardless of blood glucose level
 Acute kidney injury and impairment in renal function: consider temporarily
discontinuing in settings of reduced oral intake or fluid losses
 Urosepsis and pyelonephritis: evaluate patients for signs and symptoms of UTI and treat
promptly, if indicated
 Necrotizing fasciitis of the perineum (Fournier’s gangrene): rare, serious, life-threatening
cases have occurred in both female and male patients; assess patients presenting with
pain or tenderness, erythema, or swelling in the genital or perineal area, along with
fever or malaise
Barriers to Medication Titration
1. Abnormal renal function and/or hyperkalemia / established renal disease
2. A decrease in eGFR of >30% or the development of hyperkalaemia -- dose reduction
required
3 In hypovolemia, the dose of diuretic agents should be reduced
4. The ARNI dose may also need to be reduced in the setting of renal insufficiency or
hypotension
5. Monitoring should be dictated by the clinical stability of renal function and volume
status
6. Cost of therapies -- a substantial barrier to care
7 Virtual care and home visiting nurse services may aid in remote optimization of GDMT
8. Below-target doses of multiple classes of GDMT are likely more effective in reducing
risk than large doses of 1 or 2 agents.
Testing and Medication Titration Following Diagnosis of HFrEF
Studies to Consider Initially:
• BNP/NT-proBNP
• CBC, basic metabolic panel, liver function, iron studies, thyroid studies, HbA 1c
• EKG
• Chest X-ray
• ECHO
• Coronary angiogram, cardiac MRI, biopsy, other imaging as appropriate
Intensification 2-4 months

Serial Evaluation and Titration of Medications

(1-4 week cycles)

Clinic visit with history/symptoms, vitals, exam, labs

• If volume status requires treatment, adjust diuretics, follow up 1-2 weeks
• If euvolemic and stable, start/increase/switch GDMT, follow up 1-2 weeks via
• virtual visit or repeat clinic visit with basic metabolic panel as may be
indicated
• Repeat cycle until no further changes are possible or tolerated

Lack of response/instability
Remember acronym to assist in decision-making
for referral to advanced heart failure specialist:
Stabilization
~ 3 months

End-Intensification/maintenance I-NEED-HELP
• Ongoing assessment I: IV inotropes
• Additional adjustments as indicated N: NYHA 1118/IV or persistently elevated
• Repeat objective data as needed to reestablish prognosis natriuretic peptides
E: End-organ dysfunction
E: Ejection fraction ≤35%
Assess response to therapy and cardiac remodeling D: Defibrillator shocks
• Repeat laboratory tests, for example, BNP/NT-proBNP and basic H: Hospitalizations >1
metabolic panel E: Edema despite escalating diuretics
• Repeat ECHO (or similar imaging modality for cardiac structure L: Low blood pressure, high heart rate
and function) P: Prognostic medication: progressive
• Repeat EKG intolerance or down-titration of GDMT
• Consider EP referral for those eligible for CRT or ICD
Biomarkers—When to Order NP

Class I recommendation to measure BNP or NT-proBNP to support a

clinical diagnosis of HF, assess disease severity, or establish
prognosis

Always interpret NP in the context of GDMT;

Caution -- When attempting to interpret BNP values in the context
of ARNI treatment, and NT-proBNP measurement may be
preferable in this setting
Filling Pressure Assessment—When and How to Measure Filling
Pressures
1.Refractory symptoms

2.Worsening renal function

3. Repeated hospitalization for congestion

4. Well-selected patients with recurrent congestion, highly

specialized monitoring strategy with use of implantable sensors to
guide filling pressure assessment may guide therapeutic decision-
making.
 Specific Patient Cohorts in HF Care
Patient Description Evidence-based Risks Uncertainties
Cohorts recommendations

Older adults ≥75 years of  GDMT, but recognize  Potential falls Efficacy of lower-
age that this population  Worsening of renal dose GDMT on
is excluded from many function Outcomes
trials supporting GDMT  Polypharmacy
 Consider starting with  Comorbidity
lower doses of GDMT
Frail patients Meets GDMT as tolerated  Uncertain response to Ability to have an
established GDMT impact on natural
frailty  Possibly increased risk history in the frail
criteria for adverse drug with HF
reactions
How to Manage the Increasing Complexity of HF Management

Principle 1: GDMT is the foundation of HF care, and the GDMT

with the highest expected benefit should be Prioritized.

Principle 2: Target doses are associated with best outcomes.

Principle 3: Start GDMT immediately.

Delayed initiation of GDMT is associated with never initiating GDMT.
How to Manage the Increasing Complexity of HF Management

Principle 4: Attention to the clinical, social, and

financial barriers to achieving GDMT should be prioritized.

Principle 5: Diligent management of volume status

will reduce patient symptoms. Congestion drives symptoms and
hospitalizations.
If the volume status is unclear, consider performing right heart
catheterization and/or referral to an HF specialist
How to Manage the Increasing Complexity of HF Management

Principle 6: Tolerability and side effects depend, in part, on how and when
GDMT is prescribed---

Scenario1: Worsening renal function or hyperkalemia--

Use less than target doses of an ARNI/ACEI/ARB and discontinue MRA if
estimated creatinine clearance <30 ml/min or serum potassium >5.0 mEq/L.

Scenario2: ----Symptomatic hypotension

May be due to over-diuresis/ use of non-CV drugs with hemodynamic effects.
All of these should be addressed before deciding to lower doses of evidence-
based therapies
How to Manage the Increasing Complexity of HF Management

Principle 7: Primary prevention with ICD and CRT should be considered

after consistent use of optimal doses of all GDMTs for at least 3 to 6
months, followed by reassessment of EF and other indications for
device therapy.

Principle 8: Transcatheter mitral valve repair may be considered among

symptomatic patients with chronic moderate-severe to severe mitral
regurgitation despite optimal doses of all GDMTs
How to Manage the Increasing Complexity of HF Management

Principle 9: Focus on the symptoms, functional capacity, and cardiac

function.

Principle 10:- Value of therapy relate to that patient’s values, goals, and
preferences.

Principle 11: Team-based care is critical to optimizing

GDMT and may include frequent follow-up visits, telehealth visits, and
remote monitoring.
Common Cardiovascular Comorbidities Encountered in Patients With HFrEF
Comorbidity Association With Clinical Trial Evidence Suggested Action
Heart Failure for Modulating
Outcomes Comorbidity
Cardiovascular
CAD Strong Strong  Evaluate and revascularize in appropriate patients

AF/ AFL Strong Intermediate  Treat according to the current AHA/ACC/HRS

Guideline
MR Strong Intermediate  Refer to a structural heart disease expert
 Treat according to the current AHA/ACC Guideline
and ACC ECDP on the Management of MR
 Consider transcatheter intervention in carefully
selected patients with symptomatic HF and
secondary MR
Aortic stenosis Strong Strong  Refer to a structural heart disease expert
 Treat according to current AHA/ACC Guidelines

HT Uncertain Strong for prevention  Treat according to current ACC/AHA Guidelines

Common Cardiovascular Comorbidities Encountered in Patients With HFrEF
Comorbidity Association With Clinical Trial Evidence Suggested Action
Heart Failure for Modulating
Outcomes Comorbidity
Dyslipidemia Uncertain Strong for prevention  Treat according to current AHA/ACC
Guidelines and the ACC ECDP on the Role
of Non-Statin Therapies for LDL-
Cholesterol Lowering in the Management
of ASCVD Risk

Peripheral Moderate None  Treat according to current AHA/ACC

vascular Guidelines
disease
Cerebrovascular Moderate Weak  Treat according to current ASA/AHA
disease Guidelines
Common Non cardiovascular Comorbidities Encountered in Patients With HFrEF
Comorbidity Association With HF Clinical Trial Evidence Suggested Action
Outcomes for Modulating
Comorbidity
Non cardiovascular
Obesity Moderate (inverse Weak  Further data needed
association)
Chronic lung disease Strong Weak  Smoking cessation
 Optimize therapy
 Consider pulmonary consultation
Diabetes Strong Strong  Optimize therapy
 Administer SGLT2 inhibitor
 Consider consult with endocrinologist
 Treat according to the ACC ECDP on Novel
Therapies for CV
 Risk Reduction in Patients with T2D and ADA
Standards of Medical Care in Diabetes

Chronic kidney Strong Strong  Optimize RAAS inhibitor therapy

disease  Use hydralazine/ISDN if an ARNI/ACEI/ARB cannot
be used
 Administer SGLT2 inhibitor
 Consider nephrology consult

Anemia Moderate Weak  Evaluate secondary causes

 Consider transfusion in severe cases
 Common Noncardiovascular Comorbidities Encountered in Patients With HFrEF
Comorbidity Association With Clinical Trial Evidence Suggested Action
Heart Failure for Modulating
Outcomes Comorbidity
Noncardiovascular
Iron deficiency Strong Intermediate Consider IV iron replacement for symptom
improvement
Thyroid disorder Strong Weak  Evaluate and initiate treatment
(hypo or hyper)  Consider referral to endocrinologist
Sleep disordered Strong Intermediate; note that in  Refer for sleep study
breathing patients with  Treat severe obstructive sleep apnea
symptomatic  Consider referral to sleep medicine specialist
HFrEF and central sleep
apnea, adaptive servo
ventilation
is harmful

Hyperkalemia Uncertain; may limit Weak  Recommend dietary modifications

initiation and  Consider treating with patiromer (note: data
titration of GDMT regarding clinical outcomes are pending or
sodium zirconium cyclosilicate
How to Address Challenges of Care Coordination

1. Multiple medications, cardiac devices, surgery, and lifestyle adaptations, all of which
require education, monitoring, and engagement.

2. Complexity of HF care - Exacerbated by the frequent coexistence of both cardiac and

noncardiac comorbidities.

3. Risk of inefficiencies---Due to Poor ‘care delivery”, miscommunication, potential drug–

drug interactions and drug disease interactions,

4. Team-based HF care offers optimal patient outcomes

How to Integrate Palliative Care and Transition to Hospice Care

Palliative care strives to reduce suffering. Good HF management is the cornerstone of

symptom palliation

Diuretic agents—Critical component of symptom management

Worsening disease and “milestone events”(e.g., recurrent hospitalization) should trigger

heightened preparation with patients and families.

The transition from “do everything” to “comfort only/hospice” is often bridged through a
phase of “quality survival,”

Decisions should be individualized and made in partnership with the patient, their
caregivers, and their care team.
Conclusion

DISCUSSIONS AND IMPLICATIONS OF PATHWAY—

Management of HFrEF often involves multidisciplinary care.

GDMT would be expected to significantly benefit affected patients.

No guideline, pathway, or algorithm should ever supersede clinical judgment—

as clinical practice guidelines continue to evolve.
 Early Comprehensive disease-modifying pharmacological therapy

patients without
contraindications
appear to gain most
benefit from
combined treatment
with the ‘fantastic
four’
European Heart Journal (2021) 42, 681–683 EDITORIAL
doi:10.1093/eurheartj/ehaa101
1-year Mortality Risk-Reduction with HF Combination Therapies
For Patients with Ischemic Cardiomyopathy

1-year Outpatient Mortality

% of Patients

17

9.4

7
5.6
4.7

Untreated BB + RAS-i BB + RAS-i + MRA BB + ARNi + MRA BB + SGLT2-i + ARNi + MRA

Adapted: Miller RJH et al. Can J Cardiol. 2021 Apr;37(4):632-43.

• physicians caring for patients with HFrEF should not consider prescribing
either an ARNI or an SGLT2 inhibitor, but rather both therapeutic principl
• es in combination as default strategy

Volume 396, Issue 10244, 11–17 July 2020, Pages 121-128

 Triggers for HF Patient Referral to a Specialist/Program
Clinical 1. New-onset HF (regardless of EF): Refer for evaluation
Scenario 2. Chronic HF with high-risk features, such as development or persistence of one or more of the
following risk factors:
 Need for chronic intravenous inotropes
 Persistent NYHA functional class III–IV symptoms of congestion or profound fatigue
 SBP ≤ 90 mm Hg or symptomatic hypotension
 Creatinine ≥ 1.8 mg/dL or BUN ≤ 43 mg/dL
 Onset of AF , ventricular arrhythmias, or repetitive ICD shocks
 Two or more emergency department visits or hospitalizations for worsening HF in the prior 12
months
 Inability to tolerate optimally dosed BB and/or ACEI/ARB/ARNI and/or aldosterone antagonists
 Clinical deterioration, as indicated by worsening edema, rising biomarkers (BNP, NT-proBNP,
others), worsened exercise testing, decompensated hemodynamics, or evidence of progressive
remodeling on imaging
 High mortality risk using a validated risk model for further assessment and consideration of
advanced therapies, such as the Seattle Heart Failure Model

3. Persistently reduced LVEF <35% despite GDMT for >3 months: refer for consideration of device
therapy in those patients without prior placement of ICD or CRT, unless device therapy is
contraindicated or inconsistent with overall goals of care
CONTD Triggers for HF Patient Referral to a Specialist/Program
Clinical 4. Second opinion needed regarding etiology of HF; for example:
Scenario  Coronary ischemia and the possible value of revascularization
 VHD and the possible value of valve repair
 Suspected myocarditis
 Established or suspected specific cardiomyopathies (e.g., hypertrophic
cardiomyopathy, arrhythmogenic right ventricular dysplasia, Chagas disease,
restrictive cardiomyopathy, cardiac sarcoidosis, amyloid, aortic stenosis)

5. Annual review needed for patients with established advanced HF in which

patients/caregivers and clinicians discuss current and potential therapies

6. Assessment of patient for possible participation in a clinical trial

Essential Skills for an HF Team

 HF diagnosis and monitoring for progression

 Treatment prescription, titration, and monitoring
 Patient and caregiver education on disease and treatments
 Lifestyle prescription (e.g., diet, exercise), education, and monitoring
 Psychological and social support assessment, treatment, and monitoring
 Palliative and end-of-life counseling and care
 Coordination of care for concomitant comorbidities
TABLE Potential Infrastructure Components to Support Team-Based HF Care

Modality Challenges Potential Benefits

Electronic health records  Ease of access  Reduction in errors

 Interoperability with other electronic data repositories  Decision support (e.g., ACC Treat HF mobile
 Data accuracy including missing data app)
 Accurate medication reconciliation to facilitate
guideline adherence
 Patient portal to facilitate atient/caregiver
engagement, including patient-reported
outcomes and other patient-generated data (if
available)
Patient monitoring devices: (e.g.,  Accuracy  Early warning and a reduction in morbidity
scales, implanted devices,  False alert
bioimpedance devices, wearable  Cost-effectiveness
hemodynamic sensors)  Infrastructure/resource needs, including accurate data
management and triage

Wearable activity monitors  Accuracy  Physical activity coaching/adherence

 Early detection of arrhythmias (e.g., AF)

Smartphones or other mobile  Need for more useful apps or other mobile  Activity tracking
technologies technologies, including support systems in place for  Diet records
providing equipment and training for use  Weight management
 Potential privacy issues  Communication with HF team
 Prompts for medication and lifestyle adherence

ACC = American College of Cardiology; AF = atrial fibrillation; HF = heart failure.

TABLE Reasons for Nonadherence

Patient  Perceived lack of effect

 Poor health literacy
 Physical impairment (vision, cognition)
 Mental health conditions (depression, anxiety)
 Social isolation
 Cognitive impairment (dementia)

Medical condition  High HF regimen complexity

 Impact of comorbidities (e.g., depression)
 Polypharmacy due to multiple comorbidities
Therapy  Frequency of dosing
 Polypharmacy
 Side effects
Socioeconomic  Out-of-pocket cost
 Difficult access to pharmacy
 Lack of social support
 Homelessness
Health system  Poor communication
 Silos of care
 No automatic refills
 Difficulty navigating patient assistance programs

HF = heart failure.
TABLE Ten Considerations to Improve Adherence
1. Capitalize on opportunities when patients are most predisposed to adherence
 In-hospital/pre-discharge initiation following decompensation
2. Consider the patient’s perspective
 Start with the goals of therapy (feeling better and living longer) and then discuss how specific actions (medication initiation,
intensification, monitoring, and adherence) support those goals (example: ACC’s My Heart Failure Action Plan)
 Use decision aids when available (example: CardioSmart Heart Failure Resources)
 Ask patient how they learn best and provide education accordingly
 Use culturally relevant patient education materials
3. Simplify medication regimens whenever possible
4. Consider costs and access
 Become familiar with and advocate for systems that help make cost sharing automatic, immediate, and transparent
 Prescribe lower-cost medications if of similar efficacy
 Facilitate access to copay assistance
 Discuss out-of-pocket copays proactively
 Prescribe 90-day quantities for refills
5. Communicate with other clinicians involved in care, ideally facilitated by electronic health records
6. Educate using practical, patient-friendly information
 Provide a written explanation of the purpose of each medication prescribed
 Plan pharmacist visits for complex medication regimens
 Use the “teach back” principle to reinforce education

ACC =American College of Cardiology; BNP = B-type natriuretic peptide; INR = international normalized ratio; NT-proBNP = N-terminal pro–B-type natriuretic peptide.
TABLE Ten Considerations to Improve Adherence
7. Recommend tools that support adherence in real time
 Pill boxes to be filled by patient or care partner a week at a time
 Alarms for each time of the day medications are due
 Smartphone or other mobile health applications that provide an interactive platform for education, reminders, warnings, and
adherence tracking
8. Consider behavioral supports
 n Motivational interviewing
 n Participate in engaged benefit designs
9. Anticipate problems
 Communicate common side effects
 Provide instructions on when to call for refills or report problems
 Remind patients using pharmacy assistance programs that refills/reorders are not automatic
10. Monitor adherence and target patients at risk
 Inquire patients directly (e.g., “How many times in a week do you miss taking your medications?” “Have you run out of your
medications recently?”)
 Carry out medicine reconciliation at visits, with focus on discrepancies
 Assess remaining dosage units (i.e., count excess remaining tablets)
 Monitor pharmacy fills, using available clinical databases or automated alerts for failed fills and refills
 Review available drug levels (e.g., digoxin, INR) or concentrations of BNP/NT-proBNP
 Plan home-based nursing visits for appropriate patients

ACC =American College of Cardiology; BNP = B-type natriuretic peptide; INR = international normalized ratio; NT-proBNP = N-terminal pro–B-type natriuretic peptide.
TABLE Strategies to Reduce Patients’ Cost of Care
 Coordinate care (including labs and imaging) among clinicians to minimize unnecessary
duplication
 Consider limitations of medication coverage (insurance) when prescribing
 Use generic equivalents for GDMT whenever possible
 Work with a pharmacist, social worker, or patient navigator to identify and navigate
Patient Assistance Programs
 Request price matching if a drug is found at a lower cost at another pharmacy
TABLE Helpful Information for Completion of Prior Authorization Forms*
Patient Criteria
 Include HF phenotype: HFrEF; HFpEF
 Identify NYHA functional class
 Include recent measurement of LVEF with source documentation if requested
 Identify the treatment requested or the additional testing required, with indications supported by evidence and/or
guideline statements where applicable; clinical judgment, especially for testing requests, is an appropriate
rationale
 Address previous therapies used and the rationale for switching to or adding the requested treatment
 Address known contraindications to use, adverse effects, and steps intended to minimize the risks of drugs or
procedures
 Document, when appropriate, that delays or interruptions in therapy may
 cause harm to the patient
 Document all steps taken in the patient’s health record.

*Required information may vary depending on payer and state.

HF = heart failure; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction, LVEF = left ventricular
ejection fraction; NYHA = New York Heart Association.
TABLE Important Pathophysiological Targets in Chronic, Hemodynamically Stable HFrEF and Treatments
Target Therapy
Renin-angiotensin-aldosterone system ARNIs/ACEIs/ARBs, aldosterone Antagonists
Sympathetic nervous system Beta-blockers
Natriuretic and other vasodilator peptides Neprilysin inhibitor (ARNI)
Sodium-glucose cotransporter-2 SGLT2 inhibitors
Balanced vasodilation and oxidative stress HYD/ISDN
modulation

Elevated heart rate Beta-blocker, ivabradine

Guanylyl cyclase Soluble guanylyl cyclase stimulators
Relief of congestion Diuretic agents
Ventricular arrhythmias Implantable cardioverter defibrillators
Ventricular dyssynchrony due to conduction abnormalities Cardiac resynchronization therapy

Mitral regurgitation Surgical or percutaneous mitral valve repair

Reduced aerobic capacity Aerobic exercise training
General Approaches to Improving Adherence
Considerations to Improve Adherence
1.In-hospital/pre-discharge initiation following decompensation
2.Start with the goals of therapy
3. Use culturally relevant patient education materials
4. Simplify medication regimens whenever possible
5. Consider costs and access
6. Prescribe lower-cost medications if of similar efficacy
7. Prescribe 90-day quantities for refills
8. Communicate with other clinicians involved in care, ideally facilitated by electronic health records
9. Educate using practical, patient-friendly information
10. Provide a written explanation of the purpose of each medication prescribed
11. Use the “teach back” principle to reinforce education
12. Pill boxes to be filled by patient or care partner a week at a time
13. Alarms for each time of the day medications are due
14 Smartphone or other mobile health applications that provide an interactive platform for education, reminders, warnings, and adherence tracking
15. Consider behavioral supports
16. Communicate common side effects
17. Review available drug levels (e.g., digoxin, INR) or concentrations of BNP/NT-proBNP
18. Provide instructions on when to call for refills or report problems