HFrEF

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Patients with concurrent heart failure and kidney disease are not getting proper GDMT

Andi Shahu, MD, MHS

We have all seen the story play out before: a patient with heart failure with reduced ejection fraction (HFrEF) who is new to a hospital system is hospitalized for acute decompensated heart failure. A look at their complete metabolic panel shows a Cr of 2.0 mg/dL (with a corresponding eGFR of 35 mL/min/1.73m2), and despite diuresis, the Cr does not really budge. What was initially thought to be an acute kidney injury from possible renal vascular congestion or from renal hypoperfusion turns out to be a more longstanding chronic kidney disease (CKD). Because the medical team has only met the patient for the first time during this hospitalization and they “do not know where the kidney function is going to shake out,” the patient is perhaps started on a beta-blocker but no other guideline-directed medical therapy (GDMT). The patient is discharged from the hospital on only one guideline-recommended agent. Patients like this, with concurrent HFrEF and CKD, can easily get trapped in a vicious cycle in which they are recurrently hospitalized with heart failure exacerbations and varying degrees of kidney injury; their kidney function becomes an impediment to starting the crucial GDMT which will lower their mortality, reduce their likelihood of being hospitalized again, and even improve their quality of life.

This anecdotal experience is supported by data from a new study published in the Journal of the American College of Cardiology (JACC), “Kidney Function and Outcomes in Patients Hospitalized with Heart Failure.” This study utilized the Get With the Guidelines-Heart Failure (GWTG-HF) registry and analyzed over 365,000 hospitalizations with heart failure, including about 157,000 patients hospitalized for heart failure with a reduced ejection fraction (HFrEF, EF ≤40%). Hospitalized patients had kidney function all across the spectrum, ranging from those with a normal estimated glomerular filtration rate (eGFR) of ≥90 mL/min/1.73 m2 (10% of patients) to those on dialysis (5% of patients). As patients’ eGFR decreased (as kidney function worsened), in-hospital mortality rates for heart failure patients increased from about 1% for those with a normal eGFR to 4-5% for those with an eGFR <30 mL/min/1.73m2 or on dialysis.

Among patients with HFrEF, those with lower eGFR or on dialysis were less likely to be discharged on GDMT such as beta-blockers, mineralocorticoid receptor antagonists, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), or angiotensin receptor II blocker-neprolysin inhibitors (ARNI), than those with normal renal function. This pattern was consistent regardless of race/ethnicity and sex. Patients with worse renal function (measured as lower eGFR at time of discharge) were also less likely to have an appointment made after discharge.

These disparities in quality metrics for heart failure patients, particularly those with CKD, are disheartening because 1) many patients with heart failure also have concurrent chronic kidney disease and 2) hospitalized heart failure patients with worse kidney function already experience worse clinical outcomes, such as higher mortality (as shown in this and other studies). Though the use of evidence-based medical therapies is often suboptimal among all patients with HFrEF, patients with comorbid HFrEF and CKD are an especially vulnerable group who would especially benefit from treatment with medications that are proven to improve outcomes. Additionally, though they seem to less frequently have post-discharge outpatient appointments made, these patients would benefit from more (and not less) post-hospital monitoring.

This large contemporary study of patients from a major heart failure registry highlights a gap that we must address among heart failure patients at various stages of kidney disease. More work must be done to prevent or slow the progression of chronic kidney disease in heart failure patients. Finally, special attention should be given to the utilization of guideline-directed medical therapy in this vulnerable population of patients in order to help improve their outcomes, particularly when they are hospitalized for acute decompensated heart failure.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Heart Failure Management and the Challenge of Systems-Based Practice Implementation for Optimization of Guideline Directed Medical Therapy

Michel Ibrahim, MD

As the population continues to age, along with the addition of lifesaving and prolonging medical therapies, the prevalence of HF will continue to increase. In this article, we will solely focus on Heart Failure with Reduced Ejection Fraction (HFrEF), and the potential solutions to the issues with the optimization of guideline directed medical therapy (GDMT) on a systems level.

Robust evidence has established a mortality benefit of GDMT for patients with left ventricular dysfunction. Although the known benefits of GDMT have continued to solidify, there remains a visible gap among patients with HFrEF and the efficacy of treatment.

The issues that exist are likely not based on the individual pharmaceutical therapies profile. Furthermore, medication intolerance and incomplete prescription data can only partially be blamed. Nevertheless, the problems are on a bigger scale, and they involve many different components of our care system.

Let’s discuss some of the barriers to the optimization of GDMT in patients with HFrEF: patient providers and the care system. Providers, including non-cardiologists, should be trained adequately to be able to initiate patients on appropriate medications for HFrEF. They should also know the threshold to discontinue the medications, their side effects, the major contraindications, and, most importantly, when to seek help. HF patients are often complex, and it is essential to know that the different providers involved in their care should be in constant communication when it comes to their medical regimen. It is not enough to start the medication. It’s of utmost importance to continue increasing the dosages as tolerated by the patient to at least the dosages used in the different studies where these medications have shown the most benefits. Education is a key aspect, and it should involve the patient, patient’s family, providers, and everybody in the care system responsible for the patient including nurses and pharmacists. I propose 2 points among many out there:

  1. Standardized education for everybody involved in the patient’s care
  2. Standardized methods of communication between the different providers involved in the patient’s care including the patient and their families.
Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure

Figure 1. Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure1.

The purpose of this article is not to re-invent the wheel. The American Heart Association Heart Failure Summit in 2017 identified opportunities to improve care and outcomes and reduce disparities for patients with HF.(Figure 1). The purpose of this article is to remind us that we should be focusing more on implementation strategies for GDMT. We already have the tools, and, as we speak, we are adding new ones. It’s not just the tools; it is how you make use of them that will be the difference.

In summary, establishing and implementing systems of care that can help increase the number of patients on GDMT with the focus on improving medication adherence will ultimately lead to better outcomes. What is certain is that we must continue to meet the challenges of the realities of GDMT and their barriers. Our patients with heart failure depend on it.

References

  1. Pamela N. Peterson. Circulation: Heart Failure. The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017, Volume: 11, Issue: 10, DOI: (10.1161/CIRCHEARTFAILURE.118.004957)

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.