Stephen Greene, MD: Implementing Better Therapies for HFrEF

While side effects and potential adverse events are obviously important for patients to understand, could some of the benefits of new therapies or different dosages of medication supersede some of the risks?

During the Heart Failure Society of America (HFSA) 2019 Scientific Sessions in Philadelphia, PA, Stephen Greene, MD, a cardiology fellow at Duke University said in an interview with MD Magazine® the entire treatment culture in the US could change for the better if both doctors and patients get on board.

MD Mag: How do we implement better strategies implementing therapies for patients with heart failure with reduced ejection fraction?

Greene: So, I think we definitely need evidence-based strategies to improve our implementation of these therapies but no matter what the strategy that we undertake I think we definitely need to overcome a culture in the United States of a tendency to not make medication changes when we see patients in clinic and overcome this high activation energy or clinical inertia with cardio patients.

When we see a patient in practice we often talk about medication changes with that patient and both the clinician and the patient often emphasize the theoretical adverse events or risk of side effects with the drug and obviously those need to be discussed, but I think we need to give it at least equal weight to the potential risk of not trying a therapy or not trying to escalate the dose. There's risk of not trying those include potentially increased risk of dying, more hospitalization, worse quality of life and worse symptoms. So, it's really a balance of considering the risk of not trying these therapies and understanding that even if the patient tells you that they’re stable and they are stable in their exam does not mean they are a low risk given the natural history of heart failure with reduced ejection fracture.

MD Mag: What do you think the biggest hurdle is preventing a greater implementation of therapies for these patients?

Greene: I think there needs to be improved education to some extent and just recognize that heart failure has a prognosis comparable with many forms of cancer. There is a sense of urgency for oncologists and cancer patient when they receive that diagnosis. Heart failure I don't think it necessarily has that same sense of urgency among patients and clinicians and I think it we could somehow infuse that sense of urgency we would more willing to make these medication changes and we would have it more on our radar and then we do currently.

MD Mag: Do you think it is more difficult to change the mindset of the patient or the doctor?

Greene: I think it's both. I think there needs to be improved awareness both in the clinician and the patient side. Again, recognizing that even when the patients are stable that is potentially a trap. We think we don't need to make any medication changes they're doing fine but recognizing that even among patients—for example in the paradigm HF trial--there’s a sub analysis, even among patient with relatively mild symptoms, patients that have never been hospitalized so very kind of essentially stable heart failure with reduced ejection fracture.

Those patients had a 2-year rate of death or hospitalization of about 20% so again we have a very high event rate in that subgroup who have never been hospitalized before very mild

symptoms when they see you in the office, but again something that we can't ignore

is that event rate.