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Cardiologist Connect

March 15, 2025
Reducing Hospitalizations and Improving Patient Outcomes in Heart Failure Management

Heart failure (HF) remains a leading cause of morbidity, affecting an estimated 6 million adults in the U.S. The clinical benefits of guideline-directed medical therapy (GDMT) in heart failure, particularly in patients with reduced ejection fraction (HFrEF), are well-documented, with studies showing a mortality reduction of over 70%. Despite this, GDMT remains underutilized, with significant gaps in implementation across patient care settings, especially in outpatient care.

Recent data show that while hospital-based interventions effectively optimize GDMT during acute HF exacerbations, challenges persist in outpatient settings in ensuring sustained GDMT optimization. Fewer than 20% of outpatients with HFrEF achieve target β-blocker doses, and only 10% undergo dose adjustments over the following year. These gaps highlight the critical need to improve GDMT implementation across care settings.

Innovative strategies, including digital health technologies, are addressing these challenges by empowering patients and facilitating continuous engagement. Tools like wearable devices, telemedicine platforms, and educational apps have demonstrated the potential to improve medication adherence and GDMT optimization. For instance, the EPIC-HF trial demonstrated that leveraging digital solutions combining patient education and engagement tools enhances outpatient care, reduces hospitalizations, and improves long-term outcomes.

What are the primary barriers to optimizing GDMT in outpatient heart failure management?

What practical steps can HCPs take to ensure early medication uptitration in outpatient settings?

  • March 15, 2025
    The biggest barrier is the reluctance of insurance providers to cover state of the art medical care : ARNI, sglt2 inhibitors. Additionally, the out of pocket costs are Unsurmountable for most patients .
  • March 11, 2025
    I believe the biggest barrier is related to the cost of the medication. The generics are easy to prescribe for patients to get however, the SGLT2i and the ARNI’s usually have a high co-pay and patient say they can afford it. There are programs that the drug companies have over. This does not apply to Medicare patients who are the more most likely patients to have congestive heart failure. If there is something we could do for these patients it would be very helpful to keep patients on GDMT.
  • March 11, 2025
    I think a big barrier is in physician education on importance not just of starting the correct meds but titrating up. I see many patients who are started on a low dose, the prescribing doctor checks the box, and they are never titrated. As others have mentioned, this requires a lot of time and attention, so EMR-based prompts and alerts would be a helpful adjunct. I could imagine a pop up alerting the physician to a suboptimal dose and requesting a reason for low dose. If there is a good reason entered (like BP or kidney function won't tolerate), the pop up would stop being presented.
  • March 08, 2025
    What are the explanations for HF patients on GDMT at optimal dosing not exhibiting clinical improvement ??
  • February 21, 2025
    Some of the barriers initiating GDMT on the outpatient setting is the need for more constant contact with the patient regarding adverse effects and staying on top of renal function and electrolytes. HFrEF requiures ACEI/ARB/ARNI, beta blocker, MRAs, and SGLT2is, all of which require some degree of hemodynamic and laboratory monitoring making it challenging to initiate all on the outpatient setting and making up-titration challenging as well. The best way to get this done is by having staff stay in more contact with patient, have home BP and HR monitors, and have frequent laboratory analysis with staff following up on these things and transmitting them to the physician or ACP to advance medical therapy. Ideally, office visits should be utilized to further up-titrate medical therapy. Ultimately, the best thing to do is to have these medications applied prior to discharge and have the outpatient team up-titrate them for both compliance and better outcomes.
  • February 21, 2025
    Cost of nongeneric GDMT including ARNI, SGLT-2 meds is a barrier for adherence for many patients. The lab follow up is not a significant concern. Engaging the patient about goals of GDMT and partnership in this initiation assists in understanding and compliance
  • February 09, 2025
    Barriers include coverage (ie for newer agents especially) and patient (and at times provider, possibly due to unfamiliarity) reluctance. Steps to take are helping informed decision making with rationale behind multiple drugs explained, and looking into any assistance available for coverage.
  • February 07, 2025
    It is simply very healthcare provider labor intensive to up titrate patients comfortably. Shortcuts such as relying on measured vitals without attention to patient symptoms (many patients are minimally symptomatic even a blood pressure below 100 and heart rates in the 50s or lower) result in lowering of doses or failure to even attempt to titrate upwards. Similar concerns apply to borderline renal function and glucose. Close follow up with comfort in pushing the envelope knowing that it is possible to pull back if symptoms actually develop is needed, but there is insufficient MD time for this in most practices.
  • February 06, 2025
    Some of the difficulty it it is difficult to manage both side effects and cost. Sometimes an elderly patient will be discharged on all 4 pillars and have a syncopal episode post discharge and do not want to restart even at a later date. Patients need frequent and careful follow up.
  • February 05, 2025
    I think the primary barriers to optimizing GDMT are tolerability and cost. Especially with nongeneric medications, patients have found them historically unaffordable, but I am hopeful that the new changes to Medicare will help. That said, close follow-up with rapid uptitration has proven beneficial. Our process is to have the patient seen by a physician or physician extender every 2 weeks until they are on the maximally tolerated GDMT, with frequent checks of renal function and blood pressure in between.
  • February 05, 2025
    Major barriers to management of HF patients include insurance authorizations for ANRI and SGLT2 inhibitor Rx, patient compliance with therapy due to side effects. Early followup in cardiology clinic to review discharge medications and assure that current therapy matches discharge therapy is very helpful. It is amazing to see how many patients are not discharged from the hospital on the medications which stabilized them as inpatients? Possibly more frequent cardiology followups and management by cardiology of HF if allowed per insurance authorizations would be helpful. Often patients develop side effects and self-medicate and require reassurance
  • February 05, 2025
    I think the answer lies in frequent touch points with weekly followups post discharge until GDMT is achieved using a mixture of MD and APP time. Helping people adjust meds, deal with side effects and issues, is critical and widely achievable.
  • February 05, 2025
    Inadequate titration and financial issues apart from tolerance and resistance to taking multiple meds.
  • February 05, 2025
    When patients obtain an asymptomatic status and are dealing with a large pill burden from multiple illnesses, it can lead to reluctance to add CHF meds past the initial two therapies, usually beta blocker and ACEI/ARB/ARNI. As BP declines to lower level, it can lead to reluctance to push doses of CHF meds that might cause lightheadedness on standing leading to falls or feeling unwell.
    To promote CHF med titration, early follow up visit in the cardiology clinic may be provide the best chance for this, since the recent initiation of CHF medications will be most apparent
  • February 05, 2025
    In my experience the most common situation has been renal injury. In these cases MRA or ACR or ARNO could not be added.
  • February 05, 2025
    Many hesitant to start all 4,pillars of standard rx at once and 2 pillars requires operation so many visits before on optimal medical rx
    Also concern re hypotension and increased k for max dose rx
    I think physician extenders would be useful with well designed protocol to ensure proper Rx by guidelines
  • February 05, 2025
    Getting all the components of GMT started in the hospital is very helpful.
    The patients then associate all the components of treatment is key in keeping them out of the the case manager can start the process of getting the meds through insurance. Then the main outpatient job is titration. This requires frequent follow up and lab.
    Doubt telehealth and computer gadgets will make much difference.
    Most important is insurance coverage of the drugs and physician knowledge of the components of GMT
  • February 05, 2025
    Seeing patients within a week after discharge, making sure they are compliant, making sure that there is adequate coverage for branded medications, supply of samples for those who cannot afford will play a major role.
    Digital health technologies is difficult for elderly patients, however wearable devices, frequent telemedicine visits could play a pivotal role.
  • February 05, 2025
    Close follow up is very important in reference to managing heart failure patients. GMT is labor-intensive for both the patient and the physician, but is essential in reference to optimization of their management. Patients need to be seen frequently after discharge to monitor their vital signs and to make adjustments and additions in reference to the medical regimen.
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