Guidelines or Goals in Heart Failure: A Podcast with Parag Goyal, Nicole Superville, and Matthew Shuster

Eric 00:00

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:04

This is Alex Smith.

Eric 00:05

And Alex, who do we have with us today? Because I think we have someone special, a guest host.

Alex 00:12

We have a guest host who has requested this episode, Matt Shuster, who’s a geriatrician and palliative care doc. He’s in Boston. He’s a medical director of Hebrew Senior Life outpatient clinic at Newbridge. And also I was in the HVMA primary care program. That’s what it was called at the Brigham way back in the day. And Matt was one of the preceptors of a good friend of mine and classmate Dawn Sherling. And Matt brought today’s topic to us. Matt, welcome to the GeriPal podcast.

Matthew 00:43

Thank you. I’m thrilled to be here.

Alex 00:46

We also have Parag Goyal, who is a cardiologist and associate professor of medicine at Cornell. He’s the director of the program for Care and Study of the Aging Heart and director of the Heart Failure with Preserved Ejection Fraction program. Parag, welcome to the GeriPal podcast here.

Parag 01:06

Thank you. Thank you.

Alex 01:07

And I know Parag from the Beeson meetings where we sing campfire songs at night. It’s a lot of fun.

And Nicole Superville is a cardiologist and assistant professor at Wake Forest and associate director of heart failure for the Atrium Health Southern region. Nicole, welcome to the GeriPal podcast.

Nicole 01:27

Glad to be here.

Eric 01:29

So we’ve got a lot to cover. We’re going to be talking about heart failure in older adults and specifically guidelines or goals when we’re thinking about heart failure. But before we go into that topic, Matt, I think you have a song request.

Matthew 01:42

I do. And the song is entitled medication. Pretty obvious reason to pick that.

Eric 01:48

What was the reason to pick that? Or will we find it in the lyrics?

Matthew 01:52

Well, actually, we will find the lyrics. The band is called the collection. It’s actually a song that the lead singer of that group wrote about depression. But if you look closely in the lyrics, there’s a lot of references to things that have to deal with heart failure and the effects of treatments for heart failure, orthostasis, falls, dyspnea. So pay attention to the lyrics.

Eric 02:17

Alex, give us a little snippet.

Alex 02:18

Here’s a little snippet. And for those watching on YouTube, you’re going to see me with the guitar playing this. For those of you who are listening to the audio only podcast, Matt sent me the garageband version with like four different backing tracks. It’s awesome. So I’ll be singing along to that.

Eric 02:37

Feeding the beast, Matthew, feeding the beast [laughing]

Alex 02:41

All right, here’s a little bit.

Alex 02:47

(singing)

Eric 03:55

I think I see it. Matthew, I get the lyrics.

Nicole 03:58

Yeah, that was actually very fitting in terms of just how patients may feel. I feel like I should steal this and put this as an overhead for.

Alex 04:07

A heart failure clinic playing in the background.

Eric 04:15

Okay, Matt, I’m going to start off with you. What motivated you to suggest this podcast?

Matthew 04:21

Well, I actually have been teaching, doing sessions about polypharmacy for many years. And in fact, as Alex mentioned in the intro, probably more than 20 years ago, Muriel Gillig asked me to help out with the geriatric modules at the Brigham women’s hospital primary care medicine sort of sessions. And I know one of the topics I did was polypharmacy then. And Alex, you may have actually been in one of those.

Alex 04:47

Probably was, yeah.

Matthew 04:49

And so it’s been something I’ve thought about for a long time in practice. And in recent years, you know, the pace of new drug discovery and release by the FDA, it seems to have quickened a lot of great drugs, a lot of. A few drugs we scratch our heads about. But in the last couple years, I have a practice at Newbridge that is really old old. The average age is 87. And so there’s lots of folks who have heart failure, and the big majority actually have heart failure with preserved ejection fractions.

And I’m starting to see that phrase when they come out of the hospital more and more often, guideline directed medical therapy and what that means, which is often adding two, three, even four more medications on individuals who may be on 5810 more. So it’s been that conflict between, here’s a guideline, here’s some evidence, which I must say, as a generalist, it’s hard to sort through the evidence. And how do I reconcile that with what I know are some of the dangers of polypharmacy? But that’s why I picked this topic.

Eric 05:59

And Nicole, as a specialist, does that kind of ring true to you? Is this tension?

Nicole 06:04

In a way, it definitely does. In terms of that struggle in terms of here, you’re right. You have the guidelines. You have x amount of medications to choose from. And do I apply just a, hey, one size fits all approach in terms of just checking off those boxes, or do I make it a little bit more tailored in terms of my approach? When I see a patient?

I would say it’s particularly more difficult, too, because with patients with heart failure, preserved ejection fraction, you know, a lot of times they have multiple comorbidities, and so they’re already on a lot of different medications, and then, you know, you’re trying to really be selective. I personally, at least, that’s my approach sometimes. In terms of, hey, what do I add on here? Where would I get the most bang for the buck? Can I really add on three or formal medications in that particular setting? And I would imagine, too, that’s probably a struggle for other cardiologists as well.

Eric 07:09

Yeah.

Parag 07:09

So all these issues, it’s very interesting because this discussion sort of mirrors why I do what I do from a career standpoint. So in training as a cardiology fellow and then as a heart failure fellow, I got very interested in this very specific subtype of heart failure. Heart failure with preserved ejection fraction. And to your point, Nicole, these patients are older. They’ve got a bunch of medical conditions. The idea of polypharmacy or a high medication burden is nearly universal.

So as I was training and learning traditional cardiovascular stuff, I was like, seems like polypharmacy and multimorbidity. And I should probably learn more about this incorporated into how I actually think about patients and older adults. And it links back to learning a little bit about frailty and cognitive impairment. But polypharmacy was a big one. And for the past several years, I study polypharmacy because of these issues that we’re actually describing. So, really important topic, and I’m excited for these next 40 minutes or so to talk this through in greater detail.

Eric 08:14

Well, can I ask a stupid question? Because heart failure is one of those things. Like, in med school, I think we only got taught about heart failure with reduced deduction factor. We didn’t even call it back then. We just called the heart failure. And the number of meds for that has significantly increased. So that there’s this question that we will get to. And then there’s this other thing of heart failure with preserved ejection fraction, which.

Alex 08:40

I think we used to call diastolic dysfunction. Right. When we were in training, but now has a new name, heart failure with preserved ejection fraction.

Eric 08:48

And that’s not what the kids are calling it, Alex, either. Is it a HFpEF?

Parag 08:53

That’s right.

Eric 08:54

HFpEF versus HFpEFdev?

Nicole 08:59

Yes.

Eric 09:00

What is HFpEF?

Parag 09:05

Do we have a lot of evolution there?

Nicole 09:11

There’s been a lot of evolution, I would say, in the term or the entity, I would say half path. You’re right. Years ago, it was felt to be mostly just related to diastolic dysfunction. But I think the thought has really evolved far past that to where there’s a lot of ongoing research, and it seems more to be not just a cardiocentric entity, but I would say more of a systemic disease. Probably. The evidence suggests more so of aging. There’s a lot of different components in terms of just an inflammatory component, things that we see in the skeletal muscle changes in that regard.

And a lot, of course, that suggests that there are different phenotypes of HFEF. So there’s still a lot, I think, that needs to be explored, and we’re trying to learn more. Hence what makes it particularly challenging, I think, in terms of trying to figure out, you know, try to get to a one size, kind of fit all.

Eric 10:15

Approach, and it feels like, I mean, for half ref. Reduced ejection fraction, I get it. It’s a disease of older adults, like, when you look at it. But HFpEF seems like a lot of older adults have it. It is fairly common. Does that sound right, Prague?

Parag 10:34

Yeah. So as the population ages, I think this is one of the main reasons why we’ve seen a much higher prevalence of heff pEf. Part of it is also, I think the field is recognizing that there’s this subtype of heart failure. I’ll share what often happens when patients come to see us. They see doctors for years, they’re short of breath, they have fatigue, they have swelling of the legs, edema, they have all these classic symptoms of heart failure. They get an echocardiogram, which is the right thing to do. And the echocardiogram shows a preserved ejection fraction. Because this is a heart failure syndrome with a preserved ejection fraction, which is easily measured on the echo. People see that. They see it’s preserved.

And often patients are told there’s no cardiovascular problem, you don’t have heart failure, you’re older, or maybe it’s from another chronic condition or. And so, unfortunately, I think for a while, this condition, for many people, isn’t diagnosed until you end up seeing a cardiologist or a heart failure doctor who’s really honed in on this to say, actually, this is a heart failure syndrome. So, yeah, it’s great that we’re all recognizing this condition much more frequently, because, again, it does disproportionately affect older adults. And I think one key part is educating the field, not just my fellow cardiologists, but also primary care doctors, geriatricians, that there’s this heart failure syndrome that is kind of sneaky, and it’s kind of difficult to diagnose any.

Eric 12:05

Any pearls on the diagnosis of HFpEF. Should I even be using that term, HFpEF, or should I not follow what the kids are doing?

Nicole 12:14

No, HFpEF is cool, and it’s fine.

Matthew 12:18

I used it to tell the residents that I’m still in the game.

Eric 12:21

Yeah.

Matthew 12:24

I would say that in primary care, I think we see this so much now in older adults, because there are so many older adults that we’ve sort of gotten used to the idea that our questions really are for what’s the most effective treatment? We use those bnps brain natural agapeptide tests. Those get probably overused in following patients, and we see them very elevated in these folks with normal ejection fractures, and they have edema. So I think there’s recognition. But the confusion for, I believe, is coming from some great therapies that are on board, but the data seems to be really more effective for the reduced ejection fraction population, not the folks that we are seeing more and more.

Alex 13:10

Hey, before we jump to treatment, one more question. Is your impression that HFpEFde is under diagnosed in older adults? Yes, over diagnosed in older adults are about right.

Parag 13:23

So I think I would say under diagnosed. And I was going to answer Eric’s question about the pearl.

Eric 13:28

Thank you. I thought Alex was trying to bypass my pearl question.

Parag 13:33

For me, I think the biggest pearl is if you’ve got an older adult who has. Who has. Who is reporting to you progressive shortness of breath, don’t blame it necessarily on age or deconditioning. That’s the classic misclassification that I end up seeing. If it’s continuing and it’s getting worse and maybe they have some swelling in the legs, there are some subtle findings on the echo, but really think for a second, could this be this really common cardiovascular condition, echocardiogram, maybe even a referral to a cardiologist? If you have access to that, I think, is the way to go.

Eric 14:10

Yeah.

Nicole 14:10

And I would say one thing, you know, because I think Matt mentioned about the BNP levels. I think that’s another pearl I would probably say, to keep in mind, because some of these patients don’t always have elevated bnp levels. Of course, it’s a clinical picture that you’re trying to put together, but when you think about the subtype of people with obesity and HEP pef, sometimes their Bnp levels could be just fine. So I would agree, just in terms of not trying to dismiss a lot of these patients in terms of deconditioning and really trying to sometimes hone in on the diagnosis despite a Bnp level that is not necessarily very high.

Eric 14:55

Okay, I got another question. GDMT was mentioned a couple times. What is GDMT? T sounds like a new age band.

Nicole 15:07

Guideline direction, medical therapy.

Eric 15:10

Is that just pharmacological guideline, or does that include all guidelines, non pharm exercise, things like that?

Parag 15:17

So, technically, it’s the pharmacologic therapies. And that term GDMT is just a term coined in the heart failure world, which there were lots of medicines for reduced EF, HFrEF, and only recently has there been now therapies that we call GDMT for heart failure with preserved ejection fraction.

Eric 15:40

Okay. And I promise I’m going to turn it over to Matthew. Ask about or Matt about the GDMT. But given that it doesn’t include non pharmacological therapies, I got a question about one of those therapies that we always ask, like, low salt diet. This was actually just brought up to me by a med student the other day. He was describing his, like, 87 year old grandma who was placed on a low salt diabetic diet. And, like, he has to convince her every day to take this, and she would rather die than continue to this diet, and he feels like he has to force her to take it.

Where are we with low salt diet? Because I also feel like we target people’s low sodium diets in the hospital. We target their diuretics to this, and then they just go home and they eat something completely different. So we’re not targeting our intervention to what their life actually looks like.

Parag 16:29

So I have lots of strong opinions on this, but, Nicole, you can go first, and then I’ll go.

Nicole 16:34

I too, but I’ll let you go first.

Eric 16:38

Hit me.

Parag 16:39

So excessive sodium can lead to fluid retention. And I’m not saying. I’m saying excessive sodium. So what I usually counsel on is to avoid very high amounts of salt. So what are the high amounts of salt, pickles, olives, processed meats, eating out? I mean, I think those are the big ones, so I usually recommend avoiding those. But I don’t go personally as far to say low salt diet, because the concern, and there’s some studies supporting this, is that when you suggest low salt diet, caloric intake drops.

And when talking about older adults with chronic medical conditions, if you drop that caloric intake and they start losing weight because they’re not eating enough. Okay, great. They’re not eating salt, but they’re also harming themselves in other ways. So I actually explicitly will share this with patients to make sure that they appreciate that balance. I don’t want you to eat too much salt, but I need you to eat enough food to live life. Nicole, I don’t know what you think.

Nicole 17:41

No, I try to strike that balance as well in terms of, like, the salting. And I will share something just personal. So I have a two and a half year old, and during my last pregnancy, I had gestational diabetes. And boom, boy, was it hard to count those carbs. So I think that gave me a different perspective in terms of when I counsel my patients, I’m probably similar to you. I always tell them, you know, no one’s perfect. You know, you’re gonna go out. You’re gonna probably join friends at a restaurant. I don’t know what you all at. When you went to the Beeson club, was it the Beacon Club?

Alex 18:21

Beeson conference?

Nicole 18:23

Yes, the Beacon conference. But we’re not perfect individuals. I tried to tell them, hey, there were days when I just wanted a cheat day, and I was going to have my burger and fries no matter what that sugar was going to be. And so I try to practice with them more mindfulness in terms of, hey, apart from just thinking about the sodium, I want you to get in the habit of getting other clues to, particularly the weight I found very useful. In the mornings, you try to weigh yourself in whatever manner you choose to and then really think about your target dry weight.

So you go out, you probably have your steak. If you see tomorrow, that weight jumps up by, like, three pounds. Hey, that ain’t muscle mass. That is probably your body holding on to some fluid. So, you know, get in the habit of, like, hey, maybe adjusting your diuretic, and they can call the office and we kind of work through it together if things aren’t turning around. But I’m probably right there with you as well, that know, we don’t want to be too stringent. There are studies to support that. But again, mindfulness, I think, is a big issue, and that’s how I counsel.

Eric 19:32

And I love this. This is like, what Matt brought up is this guidelines versus goals. People’s goals are often much more than, you know, perfect management or heart failure, even living as long as possible. The quality of life matters more. And correct me if I’m wrong, we actually have one study. Was it sodium hf? That may be suggested. Low. Low sodium diet doesn’t really add much.

Nicole 19:56

I believe it was that one. Right.

Parag 19:59

And it’s actually, um. I gotta look back. I think it’s. I’m not even sure it’s explicitly in the guidelines anymore. In terms of low. Oh, yeah, excessively low. I’ll have to double check that.

Nicole 20:09

Even the aha, I think, you know, because I remember, you know, when we were training, they would always say, like, limited to, like, 2 grams a day. And even the Aha was a little bit more liberal than us physicians. You know, counseling, sometimes through that 2 grams or, like, 1.5, they at some point was doing, like, 3 grams or something. But certainly, I think, again, it’s a practice, I think, of mindfulness and giving patients other tools as well, in terms of trying to keep their fluid status in a great place.

Eric 20:40

All right, Matt, I’m going to. You ask the next question, and maybe we can get into GDMT.

Matthew 20:45

Well, you know what I’d like to do is just give you a snippet from a case that I’ve used in talking medicine. It’s one of my old, old patients. He’s 91, lives in assisted living, has been diagnosed with HF, HF preserved ejection. HF of 55%. Has the usual collection of chronic diseases, paroxysmal afib, hypertension, chronic kidney disease, adult diabetes, a little anemia, a little edema, a little mild cognitive impairment. Uses a walker, put some stockings on with an eight in the morning, and he’s on. And this is an. I saw him back after he’d seen the cardiologist on torsemide, betoprolol, rivaroxabam, metformin, spironolactone, aspirin, omeprazole, atorvastatin, aricepthenne, and a bunch of vitamins, and was doing okay. His weight was up a few pounds from the year before, but he wasn’t short of breath. He’s pretty sedentary. He had one plus edema.

So kind of from a primary care point of view, the guys are doing okay. And assisted living, the quote from the cardiologist and again, I get varied perspectives from different cardiologists. None of us are the same on this, of course. Mister X appears adequately compensated, although weight and edema slightly increased. Recommend adding SGLT, two inhibitor, and consider nephrolysin inhibitor arb if blood pressure tolerates to meet GDMT. And I think that phrase and seeing that kind of said to me, well, this is something worth exploring.

Parag 22:31

So there’s a lot of medicines.

Nicole 22:34

I would actually say there’s a lot to unpack there.

Matthew 22:39

And it was the idea that, well, after eliciting that long list, it almost reads as if the goal is now to add two more medicines. Yet there’s so much multi morbidity going on. And how do you know you’re doing more benefit than harm? Orthostasis lecture like, you know all the things that can go wrong. And I think as a primary care doctor, I want to know the number needed to treat. I as far as the benefit for a patient like this versus the number needed to harm. And it’s hard to get that data.

Eric 23:11

Yeah. How much is it going to help? And importantly too, when we think about prognosis, when is it going to help?

Alex 23:17

When. Yeah, what’s the lag time to benefit?

Parag 23:20

So I’m going to add another piece to this that I think about practically when taking care of patients. Some of it is certainly the GDMT itself, the actual heart failure medicines that we as a field are often promoting because of substantial benefits. It’s more substantial, you could argue, in reduced HF, but I do think also meaningful in HFpEF. But the other angle I want to add here, I’m a heart failure cardiologist who researches deep prescribing. And so my colleagues, my colleagues, when I would go to conferences, that’s an oxymoron.

Eric 23:57

They’re all contradiction, paradox.

Parag 24:00

Hey, I like you and I respect you, but I don’t understand, what do you prescribing? We’ve spent the last 20 years trying to get everyone to take more meds, not necessarily less. And my view, which is actually consistent with our field, is not that I necessarily want to de prescribe heart failure medicines or cardiovascular medicines, but I want to prescribe the right meds for the right patient at the right time. And I want to get rid of the stuff that doesn’t make any sense. Why do I bring this up? The few things that you outline, the vitamins. I don’t know. I still haven’t seen any data that supports a bunch of vitamins.

That people take aspirin. Why is the person on aspirin? Do they have coronary artery disease? Or is this for primary prevention, which has also fallen out of favor? He’s on metformin. You might argue that you could replace the metformin with an STL inhibitor. So now we’re not adding a medicine. We’re actually substituting or replacing. So I just wanted to add that layer of how I think about these things, because I agree. I don’t know if we want to keep add on therapy, add on therapy. If we can be a little bit more holistic and think through what are the medicines that are going to provide the greatest bang for your buck and get rid of the stuff that probably isn’t going to do anything. To me, that’s the first step in conjunction with understanding the patient’s priorities.

Nicole 25:18

I would agree with that. I feel like, especially in that age group, I do think more so sometimes of making substitutions rather than add on. And let me even say most times to me, I think of them as well as suggestions. I actually reach out sometimes to the primary care physician to say, like, hey, let’s talk about this. Because sometimes they have much more longstanding relationships with these patients than me meeting them for a slice in time and trying to shuffle the deck, so to speak. But another layer I would add to it is also maybe more patient centric. I don’t know. I think at the age of 91, a patient should have a say, really, in terms of, hey, I can present you with some of the reasons I think we should make a switch, but what do you think?

Do you think you want to go down that path of changing your medications? It sounds like to me, that patient felt like, hey, maybe he was doing okay. His quality of life was fine. It even seemed like they were suggesting that, hey, the physician themselves was suggesting that, hey, he’s doing okay. But I may propose this to you in terms of adding on these two medications. So I think I make the patient, at this point, weigh in as well. I think that’s another layer. And then look for areas of substitution as opposed to adding on.

Alex 26:47

Okay, I’m going to interject here. One of our first podcasts, over 300 podcasts ago, was with Nate Goldstein, who studies heart failure management in older adults, and particularly older adults nearing the end of life. And he said, the best palliative treatment for heart failure is treatment for heart failure, which to me, seems like it would push you to really consider these meds, and that would pair that with, I was reading some, doing some preparatory reading for this, and there was a great article on annals of internal medicine that Matt sent to us that we can share in the show notes associated with the podcast, and he pointed out that actually, treatment in the most frail patients had great benefit, which flies in the face of, like, well, the sicker you are, maybe the less you should consider it. Maybe it’s the sicker you are, more you should consider it. So I just have these, like, you know, these thoughts echoing around in my head as we’re talking about de-prescribing, which, of course, I’ve drunk that Kool Aid, but they’re kind of intention in.

Nicole 27:50

Contrast, you know, that’s certainly one way to think about it. I think, personally, the challenge with HFpEF, as I was saying, is I think there are a lot of different phenotypes, and a lot of times, these patients have a lot of comorbidities. So I think the approach in which, you know, somebody, the approach people might take to it, I think, is different. For example, you know, you might see some of these algorithms that tell you, hey, address the blood pressure first, prioritize the SGLt two inhibitor. Prioritize the MRA. What if somebody has atrial fibrillation? If it’s somebody who has coronary artery disease? Then you prioritize different things. So, I mean, I think, especially when you’re dealing with the geriatric population in particular, I think it’s okay to be a little bit more methodical. And again, probably trying to, at least from Parag’s perspective, I wouldn’t say it’s necessarily de prescribing, but I think thinking about ways to substitute. But I’ll open it up to you, Parag.

Parag 28:55

No, I agree. Everything you outlined, I wanted to address Alex’s point. I have a. I have a comment for both. So, the first is, there’s actually an AHA, scientific statement on palliative pharmacotherapy that just came out in the last few months that I had the privilege of participating in. One of the points in there was exactly what you’re describing, which is, well, if you manage the symptoms with heart failure therapy, some of which is GDMT, then you actually might help them feel better. And that’s actually a very patient centric, symptom based approach that you want to use at end of life. Naturally, you want to balance that with treatment burden and pill burden. But often I do continue some of those therapies at end of life.

The second point is, you made a comment about frailty. What’s interesting as someone who thinks not just about polypharmacy, but all multiple geriatric condition of the setting of heart failure, which, by the way, really common cognitive impairment, really common frailty, really common is that there’s probably a bi directional arrow between heart failure and these geriatric conditions. So, on the one hand, you want to. From my standpoint, you want to think practically, okay? If they’re frail, if they’re falling, if they have cognitive impairment, they’re at higher risk of adverse drug events. We’ve got to think through how to accommodate some of these limitations. A pill organizer, having family. But at the same time, if we can actually initiate these therapies and treat heart failure itself, you might be treating and eliminating what? Or mitigating the contribution from heart failure itself.

Eric 30:30

Yeah. In the hospice unit that I work in, what we see sometimes is people are on, like, 20 different medicines. We come in, we pretty much stop a lot of them, or most of them, but maybe give them a little bit of afterload reduction and continue the diuretics, which they often were forgetting, and then they look great, and we’re all high. And this idea of prioritizing the ones that are going to be most important. And for me, it’s a little bit easier in my head to think about that. With reduced ejection fraction for heart failure, HFpEF makes it a little bit more challenging for me.

And I think, Nicole, you said that I should think about it more as a systemic disease, like, all of these things in your body that are leading towards. So it could be obesity, metabolic syndrome, all of these things, and aging, which I would imagine makes it very hard to answer. The question that Matt brought up is, like, what’s the number to treat? Like, what’s the right thing for this patient? Because there could be a lot of things that are causing. Is that part of the problem with Heff PEF?

Nicole 31:40

I think that’s one of the challenges. I mean, we are part of our huge initiative called Heart share, for example, where, well, the NIH is investing almost 50 million over the next few years, really trying to get down to that very question. In terms of just the different phenotypes. We’re trying to build a huge repository, both a registry as well as a deep phenotyping cohort, trying to just figure out the different phenotypes and maybe more targetable interventions for HFpEF. Certainly there’s been a lot of progress, I would have, say, over the years, but I still feel like, again, just with the work that Sanjeev Shah and others have done. It really speaks to. This is not just a cardio centric entity, it is a disease of aging. And maybe there are multi organs involved in terms of us learning more and trying to approach patients a little differently.

Parag 32:38

Which, by the way, the multi organ, multi morbidity, even polypharmacy aspect, sodium glucose transport inhibitors, which we’ve talked about, STL inhibitors are a really nice medicine for them. Why? Because you’re treating multimorbidity.

Eric 32:56

My question is, all of this talk about individualizing care for people with Hep PEF, can I just click the easy button and just start them on an SGL too?

Parag 33:08

I kind of do. I put almost everyone sglt. It’s very well tolerated. What do I describe to them? Well, it treats heart failure, it improves metabolic health. Metabolic health probably plays a role in the pathophysiology of Heft Pep. It treats diabetes, it prevents progression of chronic kidney disease. I mean, that’s a huge part. A proportion of my patients. From a health profile standpoint, I would.

Nicole 33:34

Have to say the SGLT, two inhibitors, I feel like they’re one of the most forgiving classes of medications. I think they’re well tolerated. So that one, I think is the easy button that we push in terms of adding those on. And then you get a little bit more details with the nuances of other things based on the kidney function when you’re thinking about your aldactone or your rns and that sort of thing, in terms of blood pressure and so forth. So I think the sglt two s for sure. I feel like that’s a very forgiving.

Matthew 34:08

Class, but I think that’s one of the frustrations, is that I’m obviously not an expert in trials, but from my understanding, there haven’t been regimen versus regimen sorts of trials done in this field. And I want to ask both of you, as a primary care doctor, what’s most dramatic to me is when I see the harms from too much medication, the orthostasis, the fall, the hip fracture, that’s much easier to see than the 8% improvement in hospitalization and morbidity by adding drug eggs. Should I feel confident that the studies that have shown these benefits actually were adequately, including folks in the old, old group, 80, 85 and above? Of course, to lump everyone from 65 on is the same group of patients. It’s the same as lumping ten year olds with 25 year olds.

Parag 35:03

To me, Casey, this is a great topic and a great question and something I struggle with a lot and think about a lot so the reality is, over the last 20 years, real world older adults have just been excluded from clinical trials. I think it’s been better for HFpEF. Part of it is the average age is older, and part of it is, I think, as a field, not just in cardiology but broadly across the country, we recognize we’ve got to include older adults. We have to stop systematically actually excluding these patients. In the past, there were age cutoffs where patients of beyond a certain age weren’t incorporated. So we’re doing a better job.

Matthew 35:46

And dementia cutoffs. Right.

Parag 35:48

So we’re doing a better job. But I do still think those who are more frail have more cognitive impairment, have more advanced kidney disease, the, a little bit sicker older adults are not really in these studies. And so I think the question for me is not necessarily oldest old, but the more physiologic or biologically aged, how do you manage medicine in those people? And my approach has been understanding what their goals are, understanding what their staging of the disease is. If they’ve got six month life expectancy, I’m going to think about things a little bit differently.

Eric 36:31

How so?

Parag 36:32

Well, I don’t know if at six months I’m going to be as aggressive with blood pressure control, for example. I think that’s probably the most obvious. Some of these medications take, you don’t get benefit within the first few weeks. It might take six months, it might take a year, it might take a couple of years. And so I think about that aspect. So I think going slowly and being thoughtful and trying a medicine and seeing again or communicating with them, I mean, this is the nuance in medicine that we all need. The challenge is, it’s easy to say, oh, yeah, talk to them in a few days, talk to them in a week, have them come back every other week, because the time constraints and the way our, our healthcare system is built, the people at the greatest risk are these more vulnerable people. And so what happens is people just say, well, they’re older, they’re more vulnerable. I can’t risk it. I can’t start a medicine and see them six months later. So it’s hard, is what my summary is. It’s really hard.

Nicole 37:33

Yeah. And I don’t think there’s, that’s probably not a perfect answer, I think, you know, to any of this. And again, that’s why I think, to me, it’s a shared decision making sort of approach when you’re dealing with patients who are elderly and I’m talking about 80, 90 years old, which it seems like you’re referring to, Matt? I think it’s just a shared decision making. And really, as you pointed out, Parag really centered sometimes mostly with the patients and what their goals are. So to me, that’s when you’re really moving away from just the guidelines to probably like a more goal oriented sort of approach in terms of that subset of patients who are really, most of the times, as you’re rightly pointing out, not included in most of these sort of trials. So I think it’s a more tailored approach that I take and I think, you know, try to prioritize with the patient what’s important to them.

Is it adding on these kind of free, more medications to your regimen? Is that going to impact what you perceive, for example, your quality of life? Because a lot of these times, sometimes we’re talking about medications that the outcomes or the benefits are not necessarily driven by mortality. Sometimes it’s just driven by heart failure rehospitalizations. If you’re seeing a patient who’s like 80 something years old and they have not been in the hospital for years on end, are they truly getting a huge benefit from just layering on medication after medication? So it’s a complex, I think, conversation, but I think when we’re moving into particular age ranges, I make it a little bit more patient focused on what their goals are and what brings them.

Matthew 39:22

Quality of life, you know, for shared decision making is so important, but it presumes that the, on the clinician end that you have the right information to share and that’s, you know, feel a lot of uncertainty and I, what I’m going to be doing.

Nicole 39:39

So, Matt, do you refer, I guess, the majority of those patients to the heart failure specialists in terms of making those decisions?

Matthew 39:51

Most of them have come to me, have already been seeing a cardiologist or come out of a hospital if they’re a patient that has been mine for a long time and has developed what I believe is heart failure, particularly with preserve jet fraction. I mean, I will use traditional meds, symptom based, and be thinking about adding these new drugs in a sort of one by one. And I have the luxury in my clinic to see them back every few weeks and. Really?

Nicole 40:18

Yeah. So what’s the typical knee jerk reaction for most of your patients who presumably feel like, hey, I’m limping around here doing just fine, but I, whoa, I saw this heart failure cardiologist and they want to add on three more medications to my regimen. Like, what’s their typical reaction?

Matthew 40:39

You know, it’s a delicate conversation. They may have a long relationship with that cardiologist, so it requires some collaboration. And, you know, this is back and forth between the PCP and the cardiologist. And again, it’s a luxury to have the time to do that.

Eric 40:56

Well, Matt, do you say to your patient who comes in, well, I can start you on this SGL two inhibitor, where in this one study, 16% had worsening heart failure or cardiovascular death. The folks who didn’t get it had 19.5% chance.

Parag 41:14

Right.

Matthew 41:15

Right. That is not the conversation I’m gonna have. Right.

Eric 41:19

Why not? That’s evidence right there. I can show the graph. Got it on my phone right there. Evidence based medicine.

Matthew 41:27

Yeah, that’s the struggle. And if I said that the patient looked back at me and say, aren’t you the doctor? I’m paying you to tell me what to do here?

Eric 41:37

Or, that doesn’t sound like a lot, or, hey, that sounds great. Nicole, Parag, what do you think? How do you convert this, like, into meaningful numbers versus just setting potentially false hope that this will, and this is the hard thing about medicine. Right. There’s very few things that have a number to treat of one. And odds are most things have a much larger number to treat, and it’s not going to help this individual patient.

Alex 42:03

This one patient. Right.

Parag 42:05

The number needed to treat thing. I don’t know. I might say something controversial here.

Eric 42:11

Oh, boy. Like that.

Nicole 42:13

Give it to us, Parag. We love it. We love talking about it.

Parag 42:15

I think it’s helpful. Right. Lower number need to treat means that the statistical likelihood that the person in front of you may derive benefit. But there’s a fundamental problem here, which is that these are all population based studies, and the results are the average effect. You have no idea what the effect will be in any single individual patient.

Eric 42:37

And a lot of either direction, helpful or hurtful.

Nicole 42:40

Correct.

Parag 42:41

And in a lot of these studies, subgroup analyses are done, and arguments could be made that there are very specific subgroups that are actually driving the results, but those are usually determined after the fact. And so all of that is to say, this is kind of a mess. I don’t think the answer is necessarily, hey, 3% improvement. And so that’s how you’re going to have to make a decision. I think we got to move somehow in the direction of either sort of precision or personalized medicine. How you operationalize that, how you manifest that, I think, is to be determined. I’ll throw out one strategy, which is work that we’re doing, which is n of one trials.

Alex 43:21

Oh, great.

Parag 43:22

Which are kind of, you know, they’re trial and error. They’re basically formalizing what we all do in medicine.

Eric 43:27

Give me a brief, one sentence of what n of one trial is. Then I’m going to ask Nicole and Matt, another pearl from each of you when you think about heart failure. So I am going to call this your pearl. Parag, what’s this net of one trial?

Parag 43:43

So the idea of n of one trial is in a single individual. You test multiple interventions and try to determine in that single individual what is most effective. That’s what we do in medicine every day, but it’s very formal. We start in med, we see them three months later. How do you feel? I think formalizing that can help us better understand how patients are feeling with the addition of a medicine. Are they having a side effect? One possible idea for future personalized medicine. We’ll see.

Eric 44:11

Great. Love it. So you start gabapentin for pain. You dc it three weeks later because it’s not working.

Nicole 44:19

Then you try lyrica.

Eric 44:21

Oh, God. We won’t go into Gabapentin anymore. Listen to our gabapentin episode from a couple months ago. Nicole. Pearl.

Nicole 44:30

So I would also say one thing that we probably don’t have time to discuss is, and I know we spent a lot of time on pharmacotherapy, but we are looking into non pharmacological things that can be very useful in this population in terms of things like exercise training and those sort of things that may be just as beneficial from a quality of life perspective, especially even things we did not touch on apart from exercise and pharmacologic stuff, monitoring devices that sometimes help patients stay home in terms of things like cardiomem. So I think there’s a lot going on in the heart failure space and tools that we have to use. I think we’ve touched the tip of the iceberg and may make things a little bit more confusing for Matt on the primary care.

Alex 45:16

And even, and just to follow that up with all Dlane Kitsman’s work and others in cardiac rehab, I was rather shocked to read that CMS doesn’t cover.

Nicole 45:26

Cardiac rehab, not for patients with HFpEF, and so hence why we have rehab FPF ongoing. Another study looking at the benefits of physical rehabilitation in patients with HFpEF. So I think more to come.

Alex 45:43

Okay.

Eric 45:43

All right, Matt, take us home. One pearl.

Matthew 45:46

My pearl is an amazing piece of in home technology called a scale. And a rule of two plus two. If your weight is up more than two pounds, more than twice in a week or in two days, call us and let us know.

Parag 46:02

Yes.

Eric 46:03

Love that. Well, I want to thank all three of you. Oh, go ahead, Parag.

Parag 46:08

I approve.

Eric 46:12

We have all agreed on one thing at the end of this podcast. This is lovely. Alex, do you want to take us home with a little bit more medications?

Alex 46:25

(singing)

Eric 47:33

Matt, great song selection. Parag. Nicole, thanks for joining us.

Matthew 47:39

Thank you.

Nicole 47:40

Thanks for having me.

Eric 47:41

And thank you all to all of our listeners for your continued support.

This episode is not CME eligible.