Bridging the Gap in Heart Failure Management: Insights From a Pharmacy Times Clinical Forum

As the clinical landscape for heart failure (HF) continues to evolve, pharmacists are finding themselves at the center of a paradigm shift in how patients are identified, treated, and transitioned from acute to chronic care settings. At a recent Pharmacy Times Clinical Forum in Phoenix, Arizona, led by Craig Beavers, PharmD, FACC, FAHA, FCCP, BCCP, BCPS (AQ-Cardiology), CACP, a cardiovascular clinical pharmacist with Baptist Health System and an adjunct associate professor at the University of Kentucky College of Pharmacy, a multidisciplinary group of health care professionals gathered to discuss the nuances of managing HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF).

Redefining the Burden: The Shift to HFpEF

The session opened with a sobering look at the epidemiology of HF. Globally, 56 million people live with the syndrome; in the United States, that number has reached 6.7 million. Despite advances in therapy, the lifetime risk remains 1 in 4, with a 5-year mortality rate of approximately 50%.

A central theme of the forum was the increasing prevalence of the HFpEF phenotype (EF < 40%), which now accounts for more than half of all HF cases. "We have gotten better at preventing HFrEF because we’ve improved management of ischemic drivers," Beavers said. However, the rise in HFpEF is fueled by an aging population and the cardio-kidney-metabolic spectrum of disease, including obesity, hypertension, and diabetes. Interestingly, the forum noted that HFpEF often carries a higher economic burden than HFrEF due to greater outpatient utilization and higher pharmacy turnover.

Diagnostic Hurdles in Primary Care

A significant portion of the discussion focused on the difficulty of identifying HF in its early stages. Many pharmacists practicing in internal medicine and primary care noted that HFpEF is frequently "glossed over" or misdiagnosed. Symptoms like shortness of breath are often attributed to pneumonia, obesity, or aging.

The group debated the utility of biomarkers like B-type natriuretic peptide (BNP) and N-terminal fragment of the prohormone BNP. Although primary care physicians are generally comfortable ordering these tests, they may not always consider them first-line differentials for subjective complaints such as fatigue or swelling. Furthermore, there is noted variability in echocardiographic interpretation that can baffle nonspecialists. Beavers encouraged pharmacists to look beyond ejection fraction alone, urging them to educate teams on “key catchphrases” in echocardiogram reports (eg, hypertrophy) that can signal underlying HFpEF.

The MRA Evolution: Finerenone vs Spironolactone

The pharmacotherapeutic heart of the forum centered on the role of mineralocorticoid receptor antagonists (MRAs). With the emergence of newer data, the choice between traditional steroidal MRAs such as spironolactone (Aldactone; Pfizer) and newer nonsteroidal MRAs such as finerenone (Kerendia; Bayer) has become a point of clinical scrutiny.

Beavers presented a compelling comparison of trial data, specifically contrasting the FINEARTS-HF trial (NCT04435626)² of finerenone with the older TOPCAT trial (NCT00094302)³ of spironolactone. A key metric discussed was "time to first statistical significance." While TOPCAT’s American subgroup analysis suggested a benefit at approximately 248 days, finerenone demonstrated a divergence in benefit in as little as 28 days. "If you start treating patients at the time of their hospitalization or within the first 7 days, you see that benefit even more dramatically," Beavers said.

The conversation also addressed worries of hyperkalemia, which often prevents clinicians from initiating MRAs. Participants argued that the risk of the disease often outweighs the risk of the medication. "Realistically…potassium doesn’t kill people in these trials; the heart failure does," Beavers said, noting that finerenone has shown a more balanced safety profile regarding potassium levels compared with spironolactone.

Navigating Barriers: Access, Cost, and Silos

Despite the clinical data, participants highlighted significant real-world barriers to optimizing guideline-directed medical therapy (GDMT). In large health systems, pharmacists often work in "silos," where the inpatient team may initiate a branded medication like finerenone or an angiotensin receptor/neprilysin inhibitor, only for the patient to face a $700 co-pay or a rejected prior authorization (PA) at their local pharmacy.

"The hospital and the emergency department are not the places where you optimize chronic disease pharmacotherapy," one attendee said, emphasizing that without a solid transition-of-care plan, patients often fall through the cracks. Common breakdowns occur when PAs are sent to technicians who may not understand how to interpret an echocardiogram or clinical markers like hemoglobin A_1C to justify the therapy to insurers.

Informatics and the Future of Pharmacy Practice

The forum concluded with a forward-looking discussion on how pharmacists can leverage technology and multidisciplinary teams to improve outcomes. Several participants discussed using population health reports in electronic health record systems such as Epic or Cerner to identify patients with an EF below 40% who are not currently on optimized GDMT.

Another innovative model discussed was the use of HF navigators. Unlike standard care coordinators, these navigators—who are often pharmacists or nurses—act as the patient’s "best friend" through the process, running reports to find hospitalized patients with HF and ensuring they are connected to resources and follow-up appointments within 7 days.

As pharmacists increasingly operate under collaborative practice agreements, the group agreed that expanding these agreements to include independent titration and management of HF—similar to current models for diabetes and hypertension—is the next logical step for the profession.

"My vision and my hope," Beavers said, "is that you leave here with actionable items to be proactive in this process.”

For the modern pharmacist, that means not only reconciling a medication list but also actively advocating for the resources and diagnostic clarity needed to turn the tide against HF.

REFERENCES

1. Study to evaluate the efficacy (effect on disease) and safety of finerenone in participants with heart failure and left ventricular ejection fraction (proportion of blood expelled per heart stroke) greater or equal to 40% (FINEARTS-HF). ClinicalTrials.gov. Updated August 26, 2025. Accessed June 11, 2026. https://clinicaltrials.gov/study/NCT04435626

2. Aldosterone antagonist therapy for adults with heart failure and preserved systolic function (TOPCAT). ClinicalTrials.gov. Updated March 2, 2015. Accessed June 11, 2026. https://clinicaltrials.gov/study/NCT00094302