Video
Personalizing Quadruple Therapy in Heart Failure
Author(s):
Anuradha Lala-Trindade, MD, shares approaches to personalizing quadruple therapy for people with heart failure, focusing on family history, device-based therapies, and optimizing therapy early.
Anuradha Lala-Trindade, MD: In terms of how to respond or treat a patient with heart failure with reduced ejection fraction [HFrEF]. First, I take a really thorough family history. I take a history of from when they were a child through adolescence and young adulthood into adulthood, because I think it speaks a lot to how they were brought up, what their habits were in terms of exercise and diet and otherwise, whether they were hospitalized or chronically ill from an early age on or not. So that’s one; I dig deep going back.
No. 2 is, I also try to understand their current circumstances. What is the affordability for certain medications? How frequently are they able to come to the office? What is their understanding of heart failure? Have I done a good job as their clinician or their physician in relaying what heart failure actually entails and how this is a symbiotic relationship to ensure their long-term health? I really drive home the point that ejection fraction is just a number. It doesn’t relate directly, necessarily, to what the patient will be able to do. And I try to reassure them on that basis. And I spend a lot of time talking about language that is well received. That’s sort of my touchy-feely aspect of things.
Then, of course for HFrEF, I’m doing everything in my power to ensure that they are on all 4 pillars of guideline-directed medical therapy (GDMT). If, despite being on all 4 pillars, they have not been able to see an improvement in their ejection fraction, I am quick to proceed with implantable cardioverter defibrillators or cardiac resynchronization therapy. I’m also equally open to considering other pharmacotherapies, where relevant and appropriate. So, let’s say I have someone who’s persistently hypertensive, I will reach out for the appropriate additional therapies, such as hydralazine, nitrates, or vericiguat. Again, I’m seeking to address their comorbid conditions, like we talked about for diabetes, A-fib, etc, so I’m really trying to get those nailed down and employing a team of clinicians that can help take care of that individual.
And then I’m considering other device-based therapies. Is this someone who’s frequently hospitalized? Is this someone who would really derive benefit from PA [pulmonary artery] pressure sensor monitoring and remote management of their heart failure? Are there other reconstructive therapies that may be in clinical trial that might be a good fit for this individual? Is this someone who may benefit from cardiac contractility modulation? I would say my practice has evolved to being more open, such that once I’ve optimized a patient quickly, expeditiously to maximal doses of GDMT, I’m also simultaneously considering the impact and role of device-based therapies.
One cannot emphasize enough how important it is to start early, in terms of optimizing guideline-directed medical therapy and ensuring rapid up-titration, as tolerated. And I think the best study to show us that was conducted by Alexandre Mebazaa, MD, PhD and others in the STRONG-HF study, which really showed that it was safe and important to get patients on all 4 pillars of guideline-directed medical therapy early on in the hospitalization with rapid up-titration within weeks of discharge.
So, the TRED-HF study was a very interesting one, just over 50 patients, but it gave us so much information that was so valuable to our community. What we have recognized, and it used to be a black hole, and I will say that there’s still room for more data, but we have enough at least to understand this much. If you’ve previously had reduced ejection fraction that has now improved, you likely need to stay on all 4 pillars of guideline-directed medical therapy, as tolerated. And I say “likely” not to be flexible —it is the rule—but only to just recognize the need for individual tailoring sometimes, where applicable. So, I think TRED-HF showed us that in individuals where guideline-directed medical therapy was discontinued, there was a very high rate of recurrence of symptomatic heart failure and a subsequent reduction in ejection fraction once again. So, it is my rule of thumb, once you’re on GDMT for HFrEF, you stay on GDMT, regardless of where your ejection fraction is.
Transcript edited for clarity
