Speaker

Tariq Ahmad MD, MPH
Director, Cardiac Transplant and MCS
Chief, Heart Failure Program
Yale School of Medicine

Slides

Keywords

Heart Failure

Key Points

• Heart failure is a major problem in terms of the amount of patients who have heart failure, the cost of the entire system and as far as illnesses go the burden of heart failure is one of the highest across our health systems. It would make sense for NIH to put a lot of resources into improving care and getting more efficient in terms of clinical trials that answer key questions to improve heart failure treatment.

• Heart failure clinicians know how to communicate the journey. They have a good understanding of prognosis and can translate that into something other clinicians and patients can understand and will lead to better outcomes.The REVeAL-HF clinical trial tried to replicate this ability to prognosticare in patients admitted for Heart Failure. We did a pragmatic clinical trial in our health system where patients were automatically enrolled if they met specific criteria. We randomized to their clinician receiving information on their one-year mortality risk vs. usual care and we passively measured to see if it made any difference in clinical decision making or outcomes. We found it made absolutely no difference.

• Heart failure clinicians say they provide knowledge about correct therapies for patients. Research does not support this notion either. PROMPT-HF trial randomized the provider getting an alert when entering orders vs. no alert. Collected data in a pragmatic fashion. Alert arm saw an increased use of GDMT. Clinicians needed an extra nudge to get patients on these therapies. We had some success but did not make close to the impact we should be making.

• Some heart failure colleagues said we are key to transplant and LVAD. There are millions of patients with heart failure, and we do 3,500-4,000 heart transplants in a year. The number of clinicians who are certified in this subspecialty is more than 1,200. Do we really need so many people trained in transplant and LVAD to take care of these patients?

• The role of the heart failure clinician is to understand the patient population and ask questions that will improve outcomes, but clinical trials have had negative results, so maybe we are asking the wrong questions.

• How can we improve things? Currently most training for heart failure focuses entirely on transplant and LVAD. Heart failure clinicians should be serving as the coordinating center for complex cardiology patients where they guide medical therapy for a majority of patients, some may need valvular interventions, EP or cath, and heart failure clinicians should be at the center of these decisions. They should also have a bigger role in QI research.
• We need to be more receptive to novel ideas and skepticism. We need to revisit our basic assumptions. Unless we completely update the categorization heart failure to reflect reality we will remain hamstrung in our efforts. Link health systems to do large studies on basic care for heart failure patients

Discussion Themes

–Heart failure patients have so many co-morbities, do we know what is guideline based care for many of the patients with CHF? Will the providers and patients agree with the decision support? Guideline directed therapy has to be more nuanced but it is difficult to reverse engineer personalization in a clinical trial.

– We learned in PROMPT-HF that clinicians don’t know or there is not enough activation engery to get patients on the therapies.

-Your observation about the mismatch between training for heart failure and practice, especially with the decline in LVAD. Are the incentives aligned to support the shift in training? QI and prevention of heart failure is not considered interesting but leaders in the field should help us move in that direction.

Tags

#pctGR, @Collaboratory1