Javed Butler, MD: Promising Heart Failure Trials and Guideline Limitations

Since the early 1970s, the ongoing prevention of cardiovascular disease in the United States has been aggressive, with an ever-growing number of trials and published data being issued at a seemingly endless rate.

Given the rate at which new trials are conducted, not all methods and medications for the prevention of cardiovascular health have been endorsed by the guidelines established by the American Heart Association and the American College of Cardiology.

In an interview with HCPLive on his virtual presentation at The Metabolic Institute of America’s (TMIOA) 2021 Heart in Diabetes sessions in New York, NY this weekend, Javed Butler, MD, MPH, MBA, chairman for the Department of Medicine at the University of Mississippi, spoke of the management of heart failure and some of the benefits and limitations of guidelines.

In recent years, ongoing clinical trials for finerenone, dapagliflozin, and canagliflozin, medications primarily used for diabetes and kidney disease, have had promising results for patients with heart failure.

Several device trials have been conducted in recent months, as well.

“But none of that matters if you don't implement these therapies to our patients, and I think that's where the guidelines become really important, because the practicing clinicians are really looking forward for guidance from the professional societies and from the experts as to how to translate these data from clinical trials to the patients that are sitting right in front of them,” Butler said.

He added that many patients treated for cardiovascular disease are not on the appropriate therapy. Patients are often affected by issues within the healthcare system, some of which are a direct result of guideline limitations.

Butler referenced the CONNECT-HF trial that was recently published in JAMA, which was a large-scale, cluster-radomized clinical trial that evaluated various strategies of implementing clinical trials results in clinical practices.

“What tends to work well, are endorsement by the guidelines, and that's why the guidelines become very important,” Butler said. “Then, depending on the level of evidence or the strength of evidence, if we can convert those guideline recommendations into quality metrics, so that really helps.”

Butler added that quality-of-care metrics have also been helpful in aiding clinicians in being able to provide the best care, especially in recent years with patient influxes.

Despite this, he suggested a 4-step process that could result in more progress in providing the best cardiovascular care, which started with a “very strong endorsement” by the guidelines.

“So first of all, obviously, very strong endorsement by the guidelines to a translation of those guidelines into quality metrics as the second (step),” Butler said. “The third is some level of accountability for the for the healthcare systems to provide the best possible care that we can and have some comparative data to look at what is happening and then the fourth is aid the conditions in some way so that they can have pathways and point of care reminder systems that they can provide the best possible care.”

Though Butler acknowledged that some of the rules established by the guidelines exist “for very good measure”, he believed the focus from the guidelines on evidence-based trials were limiting.

“I’m all for clinical trials, I'm all for more trust,” Butler said. “But today, in the absence of clinical trial evidence, or for certain conditions where we will never have clinical trust, what's a better option: to not give any guidance, or, even if it's opinion or expert based guidance, at least the guidance is coming from the experts, and develop some sort of a consensus. So again, expanding the scope of the guidelines and giving some practical tips and the guidelines will help also.”