Public Service Announcement: Guidelines Are NOT Merely Suggestions

We are doing a pretty poor job of getting our patients with heart failure with reduced ejection fraction (HFrEF) on the appropriate guideline-directed medical therapies (GDMT). It is the talk of the town (and by town, I mean Twitter- and if you are not following Gregg Fonarow, MD @gcfmd on there, you need to because he Tweets almost daily science-backed sermons about how bad we are at this).

It is time; it has been time.

We are doing our patients a huge disservice by not optimizing GDMT to reduce morbidity and mortality for a complex disease with an enormous societal burden. I say this all the time, GDMT are low hanging fruit with significant impact. We are not talking about cracking chests open and implanting mechanical pumps or new hearts; we are talking about medications that in some cases cost patients nothing. I am keenly aware that co-pays can be unaffordable, but the reasons for non-adherence to GDMT are not always financial in nature and include complex patient, physician, and systems issues including therapeutic inertia.

The data is clear, we have so much work to do. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included outpatients in the US with chronic HFrEF receiving at least one oral medication for management of HF and told us just how bad we are. Over 1/4 of eligible patients are not prescribed an angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor (ARNI); over 1/3 are not prescribed a beta blocker; and over 1/2 are not prescribed a mineralocorticoid receptor antagonist. Additionally, less than 1/4 are on target doses of GDMT and sadly, only 1%, ONE PERCENT, are simultaneously on target doses of all 3 classes.

It is time to implement the guidelines for our patients’ sake. Let us get comfortable with the 3-class approach now because as The Godfather of Heart Failure himself, Clyde Yancy, MD @NMHheartdoc, suggested at his provocative talk at AHA.19, sodium-glucose cotransporter-2 inhibitors in non-diabetics and de novo ARNI may just make an appearance on the 2021 HF guideline update. Brace yourselves.

And if we are not putting our HFrEF patients on the appropriate GDMT, we need a really good reason why. And the excuse, “well, my patient feels fine”, is not good enough, because we have more than enough data to tell us we are reducing long term bad outcomes with GDMT and “feeling fine” does not tell us who will die of sudden cardiac death and who will not.

As we go into the new year, let us make a commitment to optimize our HFrEF patients on GDMT. We owe it to them to provide the best care available to them. Be creative- technology, remote monitoring devices that keep getting better, phone calls, emails, telehealth, and HF nurses are all our friends. A navigator-led remote optimization of GDMT program like the one presented by Akshay Desai, MD at AHA.19 give me hope that creativity can improve adherence.

This is a team effort that will certainly pay off.



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