Gregg Fonarow, MD: Short-Term Care and Hospitalization as a Teaching Moment in HF

Gregg Fonarow, MD: When a patient is hospitalized for heart failure, they're at high risk for readmission, as well as mortality, and most of the cost related to the care of heart failure involves hospitalizations. The challenge, of course, has been in developing therapy for patients hospitalized with heart failure, and our approach to really try and reduce symptoms, reduce the length of stay, prevent rehospitalizations, and improve survival in these patients using short-term IV therapy has been uniformly disappointing.

What we have seen, and much of this is derived from real-world observational data and some trials, is that our chronic medications for heart failure - the guideline-directed medical therapies for heart failure with reduced ejection fraction - when initiated in hospitalized patients, can have marked benefit not just in the long term, but even in the short and intermediate term. So in-hospital initiation strategy of ACE inhibitors, AR beta-blocker therapy, and aldosterone antagonist therapy is accepted now as the standard of care. They help stabilize patients and improve short-term hospitalization risk, as well as intermediate and long-term mortality risk.

Hospitalization can also serve as a teachable moment where patients are more apt to adhere to therapy. In fact, data from PARADIGM-HF showed that when patients were discharged from the hospital after heart failure hospitalization, while on sacubitril (valsartan) added to background therapy versus the ACE inhibitor enalapril, there's actually a 38% lower risk of 30-day rehospitalization. So we really see that this type of approach is critically important. Now, there remains an unmet need for patients with heart failure with preserved ejection fraction, and we need to identify therapies there, but really this search for a magical acute heart failure drug may not really be the approach, and we should take hospitalization as the opportunity for optimizing our chronic guideline-directed medical therapies.