Shifting the Paradigm in Heart Failure

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The MD Magazine Peer Exchange “Managing Heart Failure Today: Current Best Practices and New Treatment Options” features a panel of physician experts discussing key factors to consider when making treatment decisions for patients with heart failure and their own clinical experiences with recently approved medications for the treatment of heart failure.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Michael Felker, MD, MHS, professor of medicine and chief of the Heart Failure Section at Duke University School of Medicine, in Durham, NC
• Milton Packer, MD, Distinguished Scholar in Cardiovascular Science, Baylor Heart and Vascular Hospital, Baylor University Medical Center, in Dallas, TX
• Scott Solomon, MD, Senior Physician and director of Non-Invasive Cardiology at Brigham and Women’s Hospital, and Edward D. Frohlich Distinguished Chair and professor of medicine at Harvard Medical School, in Boston, MA
• John R. Teerlink, MD, director of Heart Failure at San Francisco Veterans Affairs Medical Center and professor of medicine at UCSF in San Francisco, CA

Michael Felker, MD, MHS: It is interesting. I think we all are seeing this. There has been, I think, a surprising inertia in the clinical community about saying, “Well, my patients are doing pretty good, and I’m very familiar with these older drugs.” But, I think one thing we’re speaking to is that the data is not a subtle improvement or a modest improvement; it’s a substantial improvement, a doubling in the most important endpoint. That’s really a message that needs to get out there and be absorbed.

Peter Salgo, MD: Having been in this business long enough to see this, inertia is real.

John R. Teerlink, MD: Oh yeah.

Peter Salgo, MD: Doctors are comfortable doing what they do. They’re happy doing what they do, and their patients are kind of happy with their doctors. It’s up to the thought leaders, or the research people, to show them that this is tremendous.

Milton Packer, MD: It’s not up to us, it’s up to them.

Peter Salgo, MD: Well, you’ve got to show them.

Milton Packer, MD: No.

Peter Salgo, MD: Really?

Milton Packer, MD: We can help by doing, and by participating in, research that informs the community. We can certainly talk about the results, but the treatment of patients worldwide is not the responsibility of people around this panel.

Peter Salgo, MD: You want to know something? I’m going to disagree with you. I think it is, and I think that’s what we’re doing here, frankly. We’re bringing the message out. We’re letting people hear it. We want them to know the truth. In fact, by your presence here, you’re contradicting your own statement.

Scott Solomon, MD: It’s a partnership.

Peter Salgo, MD: It’s a partnership.

Milton Packer, MD: If our presence here would convince people that there is something important they have to do, then that’s terrific.

Peter Salgo, MD: And that’s what we’re doing.

Milton Packer, MD: If our presence, however, simply is viewed as a curiosity, then I’m not certain we’re going to have much of an impact.

John R. Teerlink, MD: But it’s incumbent upon us to actually admit that we’re asking physicians to do something that’s hard.

Milton Packer, MD: Yes.

John R. Teerlink, MD: We’ve come out of our medical training womb, if you will, with the concept that ACE (angiotensin-converting enzyme) inhibitors save lives and that ACE inhibitors are the cornerstone for heart failure therapy. We’re now asking people to replace them. What we need to get across is, yes, ACE inhibitors were the cornerstone of heart failure treatment, but this is something that’s actually better. You did the same thing with isosorbide/hydralazine—we replaced that. We did the same thing, initially, with prazosin, which was the initial vasodilator for heart failure that turned out to be no better than placebo in an original trial. So, this is not something [new]; we’ve asked physicians to do this before.

Scott Solomon, MD: But the hard part here is inertia and also [that] we only have 15 minutes to see our patients. We have to take some of that time to have a discussion with the patient about a new therapy. I have been starting to switch my patients who are already on an ACE inhibitor or an ARB (angiotensin receptor blocker) to sacubitril/valsartan. It takes a little bit of extra time, but I think, in the end, it’s worthwhile.

John R. Teerlink, MD: It’s an investment.

Peter Salgo, MD: I’m going to interrupt you for just a moment. Money—we have a more effective therapy, it prolongs life, it makes people feel better. I’m guessing it’s more expensive. Is it justifiable?

Michael Felker, MD, MHS: Yeah. In the real world, [cost is] a real issue for patients because I think it’s as important as the focus on the data. We can’t ignore that fact. The old drugs are generic; they’re inexpensive. The new drugs are more expensive. I think when you look at cost-effectiveness and other analyses, this is such a dramatic benefit. I think it’s very worthwhile, but it’s important to recognize it is a real issue.

Scott Solomon, MD: We just actually did a cost-effectiveness analysis that published in JAMA Cardiology in the last few days. [What it showed], and if you think about what is cost-effective, [was that] the American Heart Association, American College of Cardiology, and the World Health Organization say that anything that is less than $50,000 per quality-adjusted life-year is considered cost-effective. In the United States, sacubitril/valsartan comes in at about $45,000 per quality-adjusted life-year.

Peter Salgo, MD: It makes the cut.

Scott Solomon, MD: It makes the cut, but the question, of course, is, it’s certainly more expensive than enalapril, but what are we gaining? It’s really important to think of it that way.

Milton Packer, MD: And again, I hate to continue to go back to cancer as an analogy. Cancer drugs are really expensive; they’re unbelievably costly, and they have enormous side effects. But how many physicians would say, “I’m not going to give you this new cancer drug, even though it would double your reduction in the risk of death, because it’s too expensive.”

In general, the patient is not bearing the direct cost of that. The patient is bearing the co-pay, and that’s not meaningless—that’s a meaningful burden. What you’re getting as a tradeoff here is so much greater when substituting sacubitril/valsartan for an ACE inhibitor than [when] substituting one cancer drug for another cancer drug.

Peter Salgo, MD: Clearly, the physician community has to divide its concerns between the patient sitting across the table from you and then the concerns of society as a whole. But if what I heard you say is true, this drug actually makes the cut both ways. It’s better for the patient, and, in terms of cost-adjusted expense of this drug in terms of life extension, it also makes sense. Is that fair?

Scott Solomon, MD: Yeah, I think so.

Milton Packer, MD: The only meaningful cost to a patient with heart failure coming to the physician is the 5 extra minutes the physician has to take to switch the patient. [This is] traded off for 1.5 to 2 years of longer life.