Managing Patients with Chronic Heart Failure: Improving Patient Outcomes

Chronic heart failure (CHF) affects approximately 5 million patients in the United States, with an incidence of 550,000 patients per years. In 2014, a primary diagnosis of CHF accounted for 1,378,000 hospitalizations; CHF was a secondary diagnosis in 450,000 additional hospitalizations. Inpatient Medicare costs in 2014 related to CHF were $10 billion, representing $10,501 per discharged patient.

In a session in the Health Management Track, R. Scott Wright, MD, FACC, FESC, FAHA, consultant in cardiology at the Mayo Clinic, presented New Therapeutic Options in the Management of Chronic Heart Failure; Optimized Strategies to Improve Patients Outcomes. HF is a clinical syndrome characterized by dyspnea, fluid overload, and examination findings. Results of the Framingham Heart Study show improvement in survival with CHF from 1950 to 1998.

Dr. Wright described changes in classification of HF: stage A patients are at high risk for developing HF, stage B patients have asymptomatic HF, stage patients experience symptomatic HF, and stage D patients experience refractory end-stage HF. These stages reflect classification and guide referral for more advanced therapies. The New York Heart Association class 1, II, III, and IV stratifications reflect symptoms.

Guidelines from the American College of Cardiology/American Heart Association call for treating hypertension in patients with stage A HF (treatment of lipid disorders, discourage smoking, encourage exercise, prescribe angiotensin-converting enzyme (ACE) inhibitors where appropriate). For stage B patients, therapy should include all measures under stage A, plus beta-blockers where appropriate, and use of an implantable cardioverter defibrillator (ICD) in appropriate patients.

Stage C therapy includes all measures in stages A and B, plus routine use of ACE inhibitors, beta-blockers, and digitalis, ICD use in selected patients, and cardiac resynchronization therapy in selected patients. For patients with stage D HF, recommended therapy includes all measures under stages A, B, and C as well as use of mechanical assist devices, transplantation, use of a left ventricular assist device, continuous IV inotrope infusions for palliation, and hospice care.

Guideline-directed medical therapy calls for the use of ACE-inhibitors over angiotensin II receptor blockers (ARBs) and use of beta blockers (carvedilol, bisoprolol, metoprolol succinate). Earlier use of aldosterone is recommended, as well as use of digoxin and diuretics as needed. Some CHF patients have limited options for drug escalation due to blood pressure issues, decreased renal function, drug-drug interactions, side effects, and the costs of poly-pharmacy, Dr. Wright noted.

He then discussed what he characterized as the sodium/fluid challenge in HF. The average American diet includes 6 to 8 grams of salt daily; current guidelines call for intake of 2 to 3 grams daily. Increased water intake is encouraged, particularly among the aging population. Patients in nursing homes often have no control over their dietary intake of sodium, he noted, and stressed the need to individualize levels of sodium restriction.

The presentation then moved to a discussion of recent work targeting inhibitors of the neutral endopeptidase neprilysin as a strategy to augment the physiological actions of natriuretic peptides. Sacubitril/valsartan is a combination of valsartan and an inhibitor of neprilysin. In studies of neprilysin inhibition (NEPi), the number needed to treat favors the use of combined ARB/NEPi. Use of ARB/NEPi therapy should be considered in patients with recent CHF hospitalization and in younger or higher risk patients who need aggressive medical treatment. Wider use is acceptable if local health economics justify payment.

In conclusion, Dr. Wright said that treatment of heart failure requires a team approach that includes a physician, an advanced nurse practitioner or physician assistant, a heart failure nurse, electronic interaction or digital support, a dietician, a pharmacist, and supportive family and friends.