Optimizing GDMT for HFrEF: Current Challenges & Opportunities for Digital Health Innovation

In this video, cardiologists Seth Martin, MD, MHS, and Jessica Golbus, MD, speak with Sarah Riley, MSN, CRNP, CHFN, and Michael Dorsch, PharmD, MS, in a roundtable discussion on the optimization of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), including the role of digital health innovation and the barriers in the optimization of GDMT for HFrEF.

Seth Martin, MD, MHS, is a professor of medicine in the Division of Cardiology at Johns Hopkins University School of Medicine (Baltimore, MD). Dr Martin cares for inpatients at Johns Hopkins Hospital and also has an outpatient clinic. He directs the Digital Health Lab at the Ciccarone Center for the Prevention of Cardiovascular Disease and serves as the center director of the mTECH Center, part of the AHA Health Tech and Innovation Network, and a co-founder of Corrie Health, Inc.

Jessica Golbus, MD, is a clinical instructor in the Division of Cardiovascular Medicine at the University of Michigan and specializes in heart failure, heart transplantation, and mechanical circulatory support (Ann Arbor, MI).

Sarah Riley, MSN, CRNP, CHFN, is a certified nurse practitioner at the Johns Hopkins Hospital and specializes in managing patients diagnosed with heart failure at the Johns Hopkins Heart Failure Bridge Clinic and Center for Heart Failure with Preserved Ejection Fraction (Baltimore, MD).

Michael Dorsch, PharmD, MS, is an associate professor, pharmacist, and clinical researcher who studies health information technology's effects on cardiovascular disease outcomes at the University of Michigan College of Pharmacy (Ann Arbor, MI). 

TRANSCRIPTION:

Seth Martin, MD:

All right. Thank you all for joining us for a multidisciplinary discussion on heart failure. I'm Seth Martin. I'm a cardiologist at Johns Hopkins, and I have the pleasure of serving as the Center Director in our HA Health Tech network where we have a collaborative project focused on heart failure. I'm going to go around and introduce our other experts. Sarah, do you want to start?

Sarah Riley, MSN, CRNP, CHF:

Sure. Hi, my name is Sarah Riley. I'm a nurse practitioner at Johns Hopkins. I work in our heart failure department with the division of cardiology, and we work in the Heart Failure Bridge Clinic, which bridges the gap between hospital discharge and home with patients with a diagnosis of heart failure. And I also work with our advanced heart failure folks awaiting transplant.

Seth Martin, MD:

Thank you for joining. Sarah. Jessie, do you want to go next?

Jessica Golbus, MD:

Hi, I am Jessie Golbus. I'm a heart failure and transplant cardiologist at the University of Michigan, and I'm really interested in how we can use mobile health technologies for behavioral modification for patients with cardiovascular disease, with a particular interest in applying that to heart failure. So as part of that, I'm also part of our AHA SFRN on Health Technologies in Innovation in which we're doing a collaborative project looking at the implementation of GDMT using mobile health technologies.

Seth Martin, MD:

Awesome. Thanks, Jessie. And then Mike.

MIke Dorsch, PharmD, MS:

Hi, I'm Mike Dorsch. I'm a pharmacist. I'm a clinical researcher at the University of Michigan College of Pharmacy, and also the University of Michigan Cardiovascular Center. I'm also a member of the Health Tech SRN through the American Heart Association and researching GDMT and heart failure.

Seth Martin, MD:

Well, it's wonderful to be back with you all for round two of our discussion on optimizing GDMT for heart failure with reduced ejection fraction. We're going to cover current challenges and opportunities for creative approaches, including digital health innovation. So, why don't we start with you, Jessie, if you could provide a quick review of GDMT for HFrEF and get into some of the challenges and opportunities for digital health innovation?

Jessica Golbus, MD:

Yeah. Well, it's no small task to give a brief review of GDMT, but I will do my best here. So, as many of you know we have four main pillars of guideline-directed medical therapy, although we certainly have many supporting therapies at this point, but we know that each class of guideline-directed medical therapy reduces a patient's risk of getting hospitalized for heart failure or dying from heart failure by about 30%. And if patients are on all four classes of guideline-directed medical therapy, that risk goes down by about 70 or 72%. So it's really critically important that we get all of our patients on therapies. We know that the biggest benefit is from getting on each class of guideline-directed medical therapy, but we think that there's an incremental benefit, or we know that there's an incremental benefit to increasing the doses of medications.

So, there's not only the challenge of getting everybody in all four classes, but there's also the challenge of increasing the dose and then monitoring patients. And so that's frequent lab draws and symptom checks because we can certainly up titrate therapies in a vacuum, but if we don't know if patients are feeling, how they're feeling, how dizzy they are, how short of breath they are, then we are really missing a big piece of that puzzle. So that's really a huge challenge and relies on a multidisciplinary approach, and I think it's really easy for people to fall through the cracks. And so that's really where there are opportunities to try and improve and streamline workflows and utilize mobile health technologies.

Seth Martin, MD:

Thanks, Jessie. And Mike. We're fortunate to have Mike because he's been a leader in this research field to use technology to improve the optimization of GDMT in the heart failure population. So Mike, it'd be great if before we get into the solution side of things, I think developing a solution is kind of a deep understanding of the problem, the barriers, so would you mind sharing with us your current perspectives on the main barriers to GDMT optimization and heart failure?

MIke Dorsch, PharmD, MS:

Yeah, sure. So we know that there's probably more than half the patients with heart failure are cared for by primary care as opposed to cardiologists. And so there really needs to be a partnership and an approach that primary care can be drivers of the initiation and titration of GDMT. So I'd say that's one piece. The other piece that we can kind of tackle is once patients have heart failure being a little bit looser with our cutoffs for blood pressure and heart rate and things like that for titrating medications and initiating the medications.

We know that people, as they progress in heart failure, are going to have lower blood pressures. And so really having a conversation with patients about their symptoms and how they can tolerate going up on their medications is really important because as Jessie pointed out, we know that initiating GDMT and titrating up GDMT to target doses really improves outcomes in these patients. And so if we can focus on partnering primary care and also in being accepting of lower blood pressures and heart rates and things, and monitoring patients serum creatinine and potassium, we can actually titrate these medications safely.

Seth Martin, MD:

Thanks, Mike. That's super helpful. And as we think about overcoming these barriers, Sarah, it'd be great to get your insights from Heart Failure Bridge Clinic. One thing you mentioned earlier was that you have partnership with community health workers, for example. So maybe you could speak to some of the strategies that you've taken in Heart Failure Bridge Clinic to overcome these barriers.

Sarah Riley, MSN, CRNP, CHF:

Sure. Also, just to add to what Mike said, a lot of this falls on us for educating the patients. I find that so many patients come to us and they're like, well, why are we going up on this? Why are we going up on this? And they're constantly thinking, something's getting worse or something's wrong, because in their head in the past, they've been given medications when they're doing poorly. And so it's kind of a change in perspective for them to say, we actually want to get you on higher doses. Our goal is to up titrate these agents to the highest tolerated dose. And so that's kind of a change in mindset that takes a while to educate the patient and have them gain our trust to be able to say this is why we're doing this. This is why we're going to be seeing you so frequently to get these things done.

And so a lot of my job is just educating and talking to them about these things. As far as overcoming some of these barriers and gaps, like I said, we do have a community health worker that is able to go out into the community and assist these patients with grocery shopping, selecting good food choices, or trying to figure out transportation to come in. Transportation barriers are a huge part of getting patients to be able to come into clinic. So if we're able to not get them into clinic, we're able to do a telemedicine visit. But some of these patients don't have the capacity to do that. So this community health worker and some of our other social resources can go out and set them up and get them established to be able to have us communicate with them and get these agents on board and up titrated.

Seth Martin, MD:

Thanks, Sarah. Yeah, and what you said about education really resonates with me. And I think that does lead into the topic of digital health that we wanted to discuss some more. For me, digital health is really powerful at bringing patient education together with the tools to actually follow the behaviors that you need to on a daily basis. And Jessie, maybe you could share some of your latest thoughts around the role of digital health for GDMT, for HFrEF. Of course, we've all been working in this HA Health Tech network on that topic, and education has been something that we've been working to collaborate with HA and our Stanford colleagues and other colleagues at other centers to really pair the educational piece together with the tools to act according to guidelines.

Jessica Golbus, MD:

Yeah, thanks Seth, for highlighting that work and for this question. So when I think about the role of digital technology in heart failure optimization, I think the real opportunity is that it can provide longitudinal monitoring and care for patients outside of these very episodic siloed encounters that we have with patients every three months, every six months. The technology really offers a way for patients to integrate within our heart failure community longitudinally. And I think that it acts in a couple of ways. It really, one, provides a structured approach to data collection, and that allows us as heart failure providers to have the information that we need to up titrate medical therapies. And it also holds us accountable. It's not like I'm depending on myself to remember that in two weeks I'm supposed to follow up with this patient or look at their labs or my nurse to remember.

It's really kind of holding us accountable as we get that data in real time. I think it also offers a real opportunity for patients to engage in their self-care by understanding their heart failure condition. I mean, really opportunities for guideline-directed medical therapy up titration. And then I think that third piece that mobile technologies can help with is the education piece, which has been so nicely highlighted. I joke that I have an education spiel that I could just play an audio recording to myself, myself to patients at their first visit because I have so much education that I want to give them, and I give it in a very kind of structured way every time so that I don't forget. But in reality there's no way that patients can absorb all of that information that I'm giving them at a single visit. And so mobile health technologies have the opportunity to give bite size education when patients need it at the right time, as guided by other aspects of their heart failure care. So I think there really is a lot of potential to transform the way we care for heart failure patients.

Seth Martin, MD:

Thanks, Jessie. I totally agree. Yeah, the digital health side can provide this reinforcement again and again. They can have the animated videos and watch it multiple times at home over time, but then also following up with you in clinic or in Heart Failure Bridge Clinic or seeing Mike and getting the education reinforced multiple times can really, then it kind of gets through. So I think this has been an awesome conversation. I wonder before we go, if maybe we could share any kind of take-home messages or resources that you want to point our listeners to if they're interested in diving more into this topic. Sarah, maybe we could start with you.

Sarah Riley, MSN, CRNP, CHF:

Sure. So we use a lot of resources from HFSA, AHA, ACC for a lot of our patients. We also try to keep it very short and sweet for our patients. A lot of our patients, as Jessi said, have difficulty absorbing a ton of information. So we have some one-pagers that we've developed about weighing yourself daily, low sodium diet, fluid restrictions, and everything like that. So whatever it is you decide to distribute to patients, I would just make it short and sweet and then you can build on it with subsequent visits.

Seth Martin, MD:

Thank you, Sarah. Jessi.

Jessica Golbus, MD:

Yeah, I mean, I think the biggest take home for me is that just the challenge of heart failure is so monumental and there are so many areas that need to be tackled from guideline-directed medical therapy to management of comorbidities, frailty, depression, the social support that our patients need, caregivers. Really, all of these need to be addressed, and there is so much opportunity for improvement and really kind of leveraging the resources at your institution to bring a multidisciplinary approach to addressing these multi-pronged aspects of heart failure care.

Seth Martin, MD:

Thanks, Jessie. And Mike.

MIke Dorsch, PharmD, MS:

Yeah, I think I'll echo one of the things that Jessie mentioned when she was talking, is having some sort of standardized approach for heart failure patients. I think that's really important. There are repeople that talk about checklists and things like that, which is getting to the point of almost like clinical decision support, where you have these things that you do a touchpoint every time with a patient, whether that's talking about their medications, talking about their diet. So all those things should be kind of touched on in a visit, which would be great.

Seth Martin, MD:

Great. Thanks, Mike. Well, I thought this was a fantastic conversation. Really appreciate all of you for your time and expertise. And thank you to our listeners for tuning in.