Optimizing GDMT for HFrEF

In this Roundtable Wrap-Up, we offer an abbreviated version of the 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.

For more expert insights, watch the full Multidisciplinary Roundtable.

The content below has been edited for space and clarity.

 Michael Dorsch, PharmD, MS, on the main barriers to GDMT optimization and heart failure

We know that more than half the patients with heart failure are cared for by primary care physicians 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. 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.

 Jessica Golbus, MD, on some of the challenges of treating patients with HFrEF with GDMT

There's not only the challenge of getting everybody in all four classes of GDMT, but there's also the challenge of increasing the dosages and then monitoring patients. That involves frequent lab draws and symptom checks because we can certainly up titrate therapies in a vacuum, but if we don't know what the patients are feeling, how they're feeling, how dizzy they are, or how short of breath they are, for example, then we are really missing a big piece of that puzzle. So that's really a huge challenge and relies on a multidisciplinary approach. 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, on digital and patient education

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.

 Sarah Riley, MSN, CRNP, CHF, on the strategies to overcome these challenges

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 dosages going up? 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 us to say that 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. We need to be able to say this is why we're doing this. This is why we're going to be seeing you so frequently.

 Dr Golbus on the role of digital technology in heart failure optimization

I think the real opportunity is that digital technology can provide longitudinal monitoring and care for patients outside of these very episodic siloed encounters that we have with patients every 3 months, every 6 months. The technology really offers a way for patients to integrate within our heart failure community longitudinally … For one, it 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 2 weeks I'm supposed to follow-up with this patient or look at their labs or my nurse to remember.

And then I think that third piece that mobile technologies can help with is the education piece … 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. I think there really is a lot of potential to transform the way we care for patients with heart failure.