Opportunities to Improve the Management of Patients With Heart Failure

Pharmacy Times Health Systems Edition, January 2021, Volume 10, Issue 1

Updates in heart failure management were presented in a satellite symposium at ASHP’s Virtual Midyear Exhibition and Clinical Meeting.

PTCE would like to acknowledge Merck Shartp & Dohme Corp for their generous support of pharmacist education.

Updates in heart failure (HF) management were presented by Ty J. Gluckman, MD, and Toby C. Trujillo, PharmD, FCCP, FAHA, BCPSAQ Cardiology, in a satellite symposium titled “Managing Preserved and Reduced Ejection Fraction in Heart Failure: An Evidence-Based Case Review” at ASHP’s Virtual Midyear Exhibition and Clinical Meeting.

Dr Gluckman began the presentation with an in-depth overview of HF, its different classifications, prevalence, causes, pathophysiology, and clinical presentation. He went on to discuss the current guideline recommendations for heart failure with reduced ejection fraction (HFrEF). The established classes of medications for guideline-directed medical therapy (GDMT) were reviewed, including indications, contraindications, target doses, and monitoring parameters. Dr Trujillo added to the discussion in this section by introducing a patient case and engaging the audience in a conversation about strategies to optimize the patient’s GDMT.

Dr Gluckman continued the presentation by introducing several newer agents that have shown benefit in certain patients with HFrEF. The first agents, sodium-glucose cotransporter-2 (SGLT2) inhibitors, were initially approved for the management of diabetes by preventing the reabsorption of glucose. However, cardiovascular benefits were also observed, such as reduced plasma volume, lower cardiac preload, reduction of blood pressure, weight loss, and improvement of endothelial function. These advantages were supported by decreases in hospitalizations due to worsening heart failure or cardiovascular (CV) death within the DAPA-HF trial for dapagliflozin and EMPEROR-Reduced trial for empagliflozin.

Secondly, vericiguat, whose novel mechanism of action in HF is that of a soluble guanylate cyclase stimulator, has emerging study data suggesting that it can prevent and potentially reverse left ventricular hypertrophy and fibrosis and even reduce ventricular afterload through both systemic and pulmonary vasodilation. Results from the VICTORIA trial were presented, which demonstrated that vericiguat significantly reduced CV death or first hospitalization for HF.

Lastly, clinical trial data for omecamtiv mecarbil, a selective cardiac myosin activator, were presented. Omecamtiv mecarbil has the potential to increase the energetic efficiency of myocardial contraction. The GALACTIC-HF trial was presented which demonstrated that omecamtiv mecarbil significantly reduced CV death or a first heart failure event. Dr Trujillo discussed dosing, monitoring, and counseling considerations for these newer agents and ended this section with a second patient case to allow the audience to further engage in discussion.

Dr Gluckman transitioned to discuss heart failure with preserved ejection fraction (HFpEF). He described the pathophysiology and current guideline recommendations, highlighting that treatment options for HFpEF are limited. This continues to remain an area of unmet need as there are not many effective treatment agents available for HFpEF. Dr Gluckman discussed agents that are being studied for their utility in HFpEF.

Dr Trujillo continued the conversation by emphasizing the important role a pharmacist can play in the management of HF. Pharmacists can help to identify opportunities to intensify medication regimens and titrate medications to target doses. He shared evidence-based outcomes data which reinforced that these activities have a direct impact on patient outcomes. The program concluded with one last case discussion, but this time, for a patient with HFpEF. He concluded by reaffirming that HF therapies are underutilized—and often underdosed—and therefore remain an area of opportunity for pharmacists to intervene. Pharmacists can remain up-to-date on emerging therapies and assist in incorporating them into practice as they are approved.