Don’t hesitate with heart failure drugs

3 minute read

When patients get side effects, there’s a tendency to stop treatment. But a leading cardiologist urges doctors to persist.

Doctors need to prioritise the treatment of heart failure, according to a leading Australian cardiologist.

Major new drugs have changed recommendations in treatment guidelines, but research suggests that even traditional treatments have been underused, said cardiologist Professor Andrew Coats, heart failure expert and dean of the Royal Australasian College of Physicians.

The most common reason given for a lack of uptake was that the treatments weren’t tolerated, Professor Coats told the annual scientific meeting of the Cardiac Society of Australia and New Zealand in the Gold Coast last month.

And if a patient experienced side effects, there was a tendency to stop treatment, he told TMR.

“Say you give a pill and then the patient says they feel slightly dizzy. And you say ‘okay, I’ll stop’, as opposed to making multiple attempts, double checking, and getting them over the first few days.”

While it could be challenging to overcome these barriers, Professor Coats urged doctors to prioritise heart failure management.

“In routine practice it’s difficult to do everything that you should do and quite often you say, ‘oh look, I’ve tried my best, this is as far as I could get’. The question is whether you’ve really tried hard enough.”

The comments come in the wake of a new consensus statement, co-authored by Professor Coats, that emphasised the need for the “big four” drugs to reduce CV deaths.

SGLT2 inhibitors were added to the list of evidence-backed treatments for HFrEF, and experts advocated combining the diabetes drug with an angiotensin receptor neprilysin inhibitor or an ACE inhibitor, with a beta blocker and a mineralocorticoid receptor antagonist.

The combination of these drugs could add years to someone’s life, compared to just using an ACE inhibitor and beta blocker alone, the authors said.

SGTL2 inhibitors were also likely to help patients with heart failure with mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF).

In that consensus statement, Professor Coats and colleagues called on doctors to step up pharmacotherapy in heart failure patients, saying most patients weren’t even close to being on all four.

Meanwhile, a study in the Australian Journal of General Practice found that less than half of all Australian heart failure patients were referred to a cardiologist.

“This finding is concerning because there is evidence that early collaborative care between a GP and a cardiologist are associated with improved outcomes in heart failure.”

Low referral rates may be explained by poor recognition of the heart failure diagnosis, the authors said.

The study, led by Melbourne GP Professor Ralph Audehm, also found that heart failure patients visited their GP more than once a month, or 14 times a year on average.

Patients with five or more comorbidities saw their GP 27 times per year on average.

But less than half of patients had a chronic disease management plan for their heart failure.

Chronic disease management plans were more likely to be implemented for other chronic conditions such as diabetes, osteoporosis and COPD or asthma, the authors said.

“This finding is troubling because chronic heart failure is associated with a worse prognosis than these other conditions.”

The five-year study of heart failure in Australian general practice analysed the health records of 20,000 people with heart failure.

“Patients with heart failure visit their GP frequently, with many not reaching guideline therapy nor referred to cardiologists. Low use of care planning and reviews presents an opportunity for GPs to improve care,” the authors wrote.

AJGP 2022, online 1 September


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