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Benefits of a multidisciplinary approach when optimizing current and integrating new heart failure treatments for improved outcomes: panel discussion
Moderator: Frank Ruschitzka (Switzerland) Panellists: Richard Hobbs (UK), Tiny Jaarsma (Sweden), Burkert Pieske (Germany), Jillian Riley (UK), and Michele Senni (Italy)
Richard Hobbs, Tiny Jaarsma, Burkert Pieske, Jill Riley, Frank Ruschitzka, and Michele Senni provide their unique perspectives on how to effectively optimize heart failure treatment through collaboration within a multidisciplinary team of primary care physicians, nurses, and cardiologists.
You know, aspirin. In heart failure, things change. The statin we can discuss, I think it is a very good point.
Senni: A good point, but this is a diabetic patient, so statins are not recommended only for cardiac disease. You never know, it’s true, if it is a very elderly patient probably we should simplify our therapy.
Ruschitzka: We bring this now to the multidisciplinary management round that we are going to have now for the next 25 minutes, but heart failure as a syndrome, it is governed by its comorbidities, that’s why it was such an excellent question and fair enough that we addressed that now; why is the patient on aspirin?
Quite honestly, I would have in heart failure without ischaemic myelopathy, I don’t see a reason. The benefit of statins in heart failure for whatever reasons, particularly in non-ischaemics are lost, they are not there and the diabetic situation we have just discussed, probably the guidelines would say metformin and here I have a question which said why did you start insulin therapy which is actually a fair point, but you will stay tuned. Diabetes and heart failure is one of the hottest topics at the moment and there we will learn more from the new trials to come.
That brings us to the multidisciplinary management and Jill, you have set that so beautifully already with a question. We doctors, I ask for blood pressure and you know what, Jill asks ‘How does the patient feel?’ That is an important point. Let’s talk about that a bit.
We want to give you tips and tricks. We all had our hands on Entresto, or LCZ we should say at these symposiums –
Ruschitzka: Rewind – exactly, but that’s fine. I’m known for saying sometimes inappropriate things, but I mean well, so that’s no problem.
We want to learn a bit from each other and that is the thing. I mentioned it earlier – it’s a bit the victim of their own success. It came out early, boom it was there, we all didn’t really know what to do. It is clearly as you have seen in all these trials and you know that now, all this data, a very convincing dataset out there and that’s why we integrate it into the guidelines and it is part of the optimised medical therapy now.
How should we proceed? You know, when you take Michele’s patient right now, Jill what do we have to do to improve our multidisciplinary management approach here? What do you want from us when we talk to you?
Senni: Frank, can I add something that I forgot? We have to say that the patient improved not only in terms of New York heart functional class, but also she was less asthenic. She was more active and what we have seen in these patients, I can tell you that they start again to appreciate their life, they enjoy their life. They start to dress well, beautiful suits. It is Italian style, let’s say. In Florence we can say it because you appreciate that. When you are in functional class III, IV you come in in your outpatient clinic dressed like that, you can figure out that this patient doesn’t feel well. This is just a small feeling.
Hobbs: It’s really important to stress this point about quality of life because particularly more elderly patients often assume that a change in their circumstance, a reduced exercise ability which reduces their socialisation is due to their ageing, not necessarily the conditions from which they suffer.
We often will just accept that these symptoms are associated with ageing as well and actually what you did with your patient is actually test a different treatment paradigm and it resulted in improved quality of life as well as potentially long-term treatment gain. We can be a little bit passive in the way we approach helping patients live more fruitful lives, even as they get older.
Riley: As is coming out here, it is a key part of everybody’s role. It is certainly not the key role of the nurse alone, it’s not the key role of the GP or of the physician or the psychologist. It is everyone, but there is another element to this that I just wonder if we think about enough, which is the social implications, the implications to the care-givers and the social reasons why somebody takes it.
We have talked about the functioning, they may take the drug because it improves functioning and your example was quite, quite clear there, that that was demonstrated in their whole wellbeing.
I also wonder if there is also something that could work as a negative there and that if it is an unknown drug, how do we actually think about those social implications and do we address those social implications - how do they understand and interpret the drug to actually encourage them to take it, so ‘I don’t just take something because you’ve told me to take it. I don’t just take it from a psychological motivation. I take it from the social implications of the way in which you’ve given me the message, I’ve read it in the daily paper’ and I just wonder if we are including that within out multidisciplinary thinking, really as moving outside and thinking about the social implications as well.
Ruschitzka: A problem I often see and I a little bit saw that from your presentations as well, I give recommendations and I see my colleagues from Switzerland who work in private practice. I send patients and there is sometimes not with them certainly, but others, not the uptake of what I propose.
Hobbs: What? Impossible!
Ruschitzka: Impossible! They don’t listen to me, then they do, so what can we do to do that better because that’s a problem now? We have a patient who comes to our hospital, has an acute decompensation or a worsening of heart failure, we start up-titrating the drugs, sometimes there is a gap, a disconnect. What can we do to make that better because ultimately this drug is a life-saving therapy and we not only can only up-titrate in clinics; that’s not the way it works. What can we do to do that better? Tiny.
Jaarsma: I think always everybody is afraid of change and that’s what I see now with the new drugs. People liked how it was and now this new drugs, so it’s a lot of ‘buts’ and how should we up-titrate and should we switch everybody. I really would like to call for this attitude change. This is an exciting drug and it can give a lot of opportunity to change working in your team to look like ‘What can we do?’ but also to work with the patient, that’s what I wanted to say, about shared decision-making, that it is not you as a physician that would say ‘Now we change you’, but also to talk to the patient and say ‘We have this new drug. What will this mean for you?’
Ruschitzka: Richard just wants to make a quick point then we have a question from the floor.
Hobbs: Yes, as far as general practice goes, these are generalists, they are looking after the totality of disease and what may seem like evidence that was a year or two ago to a specialist and therefore why isn’t this understood in common practice, you can’t make that assumption.
For the generalist, your discharge letter needs to discuss what the medication is being given for. There are acute reasons, there are long-term reasons here and they want to know whether the dose regimen stays constant, how long a patient is going to stay on it. Patients need to know this as well, but you need to reinforce for the physicians and also what monitoring is required and finally, always just talk about what to look for in terms of adverse events.
A brief summary of rationale which is what you will have given the patient but they will have forgotten by the time they get home, needs to be given to the GP because they need to reinforce these messages.
Ruschitzka: Sometimes just picking up the phone helps, too; calling, it’s very appreciated, to the point, communication is key. Let’s have a question from the floor.
Dr Susan Connelly (Imperial College, London): I am a little concerned that this late into a very good discussion that we haven’t mentioned cardiac rehabilitation. Often these patients are very functionally limited and they will benefit a huge amount from an exercise-based programme, even shifting them up marginally in their exercise capacity and it gives them access to a whole different multidisciplinary team – the psychologist, the dietician and the physical activity specialist.
Ruschitzka: Burkert, do you want to take that?
Pieske: Yes. This is a great comment and I do not know how your experiences are in London, but physical activity and exercise is key for improvements in heart failure and it should always, if possible at all, accompany optimised medical and device therapy.
We have had very good experience with that, people do improve. My dream is that we can prescribe a specific type and dose of exercise as we do prescribe medication in the future. We implemented in our department or we are just about to implement a whole training centre so in order to start this process and show that it works, of course this is nothing that can be done in a university hospital. In Germany this is completely under-developed. We have these rehabilitation clinics where people disappear for four weeks. They are good for up-titration and so on, they do this, but true intermediate and long-term partly monitored exercise is a key intervention.
Ruschitzka: Do you have ambulatory rehab programmes in your clinic? Tiny, do you know? Do you want to take that?
Jaarsma: I wanted to say that in Sweden we have prescribed exercise, just like medication you can also prescribe exercise and that is the way to go to make this serious.
Ruschitzka: This means heart failure patients should come to Sweden, I guess and get that prescribed.
Jaarsma: They are all very welcome.
Ruschitzka: You wanted to send them to Switzerland for skiing before.
Riley: If I could give just a UK perspective on it, as you know we have very well developed heart failure services, but that is one area that is under-developed, hugely under-developed. We have very good exercise cardiac rehabilitation post-MI. A lot of heart failure patients don’t slot into that and I think we can do a lot more work on it, but of course the programmes have to be modified for many patients who may well be elderly with arthritis and other comorbidities, so there is some element of modifying those. We have the programmes, but they need to be developed much more.
Hobbs: If we look at the evidence base for post-MI rehab, then it isn’t just about increasing exercise and exercise tolerance. There is an important role in patients understanding worsening of their own phenotype and the reinforcement of the importance of actually staying on prevention medication. Those components are probably just as important in heart failure rehab as they are post-MI.
Ruschitzka: Another question.
Thomas ?Tho (Reno, Nevada): Recently in the United States there has been concern about beta amyloid raising the concern about mental status change or possible dementia; how do you approach that in your practice, what kind of side effects, counselling do you tell your patients or has that been a concern for you at all practically?
Hobbs: There is a huge controversy about the etiology of dementia. Theoretically it may be amyloid deposit-based but at the moment we don’t really know. The key in this case is to have as much preventative strategy on board. Personally that’s why I would retain the statin. It isn’t for the heart failure, obviously – no evidence there – but it is going to reduce certain types of events like stroke and long-term they probably do play a role in reducing at least vascular dementia rates.
At this stage it is more the overall vascular prevention strategies and perhaps we are going to finally get better ideas about what drives dementia and indeed develop some evidence-based interventions in that big target condition for most Western health systems, because the more successful we are at helping patients survive these major vascular events. We are going to be shifting the proportion of the population that end up with dementia.
Ruschitzka: The brain is a highly vascularised organ, so there is a huge vascular component in it. But we take your comment very seriously. We are moving forward slowly now. This drug has now been introduced, it’s in the guidelines, the uptake will be massive but we have to of course safely reanalyse everything we do over the next couple of years.
So far with regard to the amyloid, to my knowledge, and that is what we have seen, there is really no data out there to be concerned.
Senni: I think, Frank that we have to specify some points, first of all that there are data from Paradigm that I’ve shown that there is no relationship at least in that trial between the use of LCZ and dementia. The second is that there are data from monkeys, experimental data that has shown that there is no accumulation of beta amyloid and thirdly there are data from healthy volunteers that there is no increase in using LCZ in these subjects.
However, there is a question from the FDA and therefore Novartis is planning, and I don’t know if this is already ongoing, a trial on assessing this point. Therefore we can wait for that but so far the data are quite safe.
Ruschitzka: We have a lot of questions but not too much time, so the multidisciplinary management is the issue and we will come to that in a second, but let’s take two questions from the floor. I have two or three here and then we will move on.
Question: If you have a patient who is a New York Heart Association Class II to III and he is on optimal medical therapy which means with an ACE inhibitor, do you stop the ACE inhibitor and replace it with the new drug?
Ruschitzka: That’s what you did, Burkert, right?
Pieske: Yes, this is what I did in this patient that I saw and I think this is what the data are. I mean, this is exactly what they did in Paradigm and this is the Class I recommendation from the New York guidelines.
Ruschitzka: Just hold that thought, because I have a question to that; is a washout needed for that? This is a question that came from the floor.
Senni: What I did, the same as you suggest, I stopped the washout period and I gave the new drug and I up-titrated the drug and the patient went back to me and said ‘Doctor, why are you giving me the new drug? I was doing excellently with the old drug and now I have low blood pressure, sweating and so on’.
Pieske: This is a very important comment because now obviously this patient experiences side effects and of course I had an interesting discussion on this yesterday evening with my American colleagues who are much more aggressive than we are here in Europe classically, typically in many aspects and also in the aspect of switching. We are conservative and I assume that your patient experienced these side effects. I do not know about the up-titration scheme that you used.
My personal impression over the years is when I switch a patient, and especially if it is a new medication, the likelihood, and we had this with the NOACs, the same experience, the likelihood that he comes back and reports some side effects, these are classical side effects, but with the NOACs we experienced this a lot. These are side effects that in my view have nothing to do with NOACs, you know? So already that you switch has a certain impact on it.
Ruschitzka: But some practical tips. What do we do? Blood pressure is an issue. Take it slowly. Of course you switch a drug and particularly with the 100 mg, there is substantial valsartan in it that your blood pressure will go down, so the 50 mg is a reasonable approach. Do you for example start in the evening, more likely when the patient is not going around?
I do that with my ACE inhibitors often that I switch them to the evening and then the patient tolerates them better because other than dumping all the drugs in the morning and then the patient doesn’t feel well during the course of the day, so what is your take on that, Tiny?
Jaarsma: I come back to the shared decision-making and talking and then to the multidisciplinary team, even if it’s nurses or people in the rehab or doctors, you have to be honest and discuss this with the patient and say ‘We are going to switch you to a new drug. It can mean this and this; you have to give it a chance, you have to give it time’.
It was the same in the beginning with the beta blockers where everybody said ‘Oh, I feel worse’, etc and if you have an open communication to say ‘This is what’s happening, this is what you can offer and please be honest with me’, and people can switch back. It’s all about being honest and open.
Ruschitzka: Jill put it perfectly right; she said to measure blood pressure and ask the patient how he feels. There are some patients who feel quite well with a blood pressure of 92 and others who will reduce to 140/120, we know that from the hypertension trials – ‘You will for a short period of time not feel better because the blood pressure is lowering, you reset a little bit the values but then you gain the benefit’. This is what it is about.
Question: Do you stop loop diuretics in this case, for example? He is on loop diuretics, low blood pressure; do you stop loop diuretics? What are the data behind? Are we confident?
Ruschitzka: Don’t forget, with the loop diuretic, with any diuretic you make any renin-angiotensin system-interfering drug more potent because you activate the rennin-angiotensin system in that case, kind of it’s a turbo, so that’s what you have to keep in mind. Sometimes if the patient is not congestive and is ..., it could actually help if you slightly reduce the diuretic. But you get a feel for it the way you move forward with it and you make your experience.
Please over there, there is a question.
Question from the floor: Yes, I have a question. From the two cases that you presented, there was the patient with the dilated cardiomyopathy.
My question is what about the patient with ischaemic cardiomyopathy, especially a young patient who experiences acute myocardial infarction, when could we start reasonably this therapy to prevent and to improve the prognosis of these patients?
Ruschitzka: Michele, do you want to take it?
Senni: We don’t have data right now. There is an ongoing trial, the transition, that will start soon about the patient that experiences heart failure after myocardial infarction.
Ruschitzka: Michele, we believe that ischaemic cardiomyopathy would –
Senni: After acute myocardial infarction.
Ruschitzka: Exactly, so the urge is to get that correctly out there. Directly after MI, that is what Michele is addressing but in general ischaemic or non-ischaemic cardiomyopathy etiology, there it is the same and that’s very clear, we are confident that there is the same benefit.
Here is a question – a lot of questions, very interactive, we love that! I have two more and then we have to conclude.
Professor Ken McDonald (Dublin): This is a question mainly for Richard. Most heart failure patients don’t see a cardiologist from one end of the year to another. You have written extensively and it is our experience also in Ireland and there is similar data from Sweden about the failure for most people with a supposed diagnosis of heart failure to get an echocardiogram.
These two things are major barriers to the rollout of any new drugs such as Entresto. What are your thoughts about a GP prescribing and the barrier that the GP in the UK, in Ireland and in Sweden will have to access to echocardiography?
Hobbs: You’re right, Ken. One of the big issues is how certain is the diagnosis and there are still quite a few patients in Europe who are being diagnosed on the phenotype, without any formal objective assessment. That almost certainly contributes to a cycle of under-management because practitioners aren’t absolutely certain that these symptoms are related to a heart failure syndrome.
It may sound ridiculous, but certainly phenotyping patients and being certain of the diagnosis at the start is critical because then you get into a stage of the patient and determining treatment strategies that are based on certainty, you are right about that.
You are also right about the fact, though that the majority of patients are going to in the end, like it or not, be managed most of the time in the community and really we know there is under-utilisation even of ACE and ARBs still.
There is particular under-utilisation of beta blockers, there is this cycle of under-management of patients and late titration on to treatments and that can only change if physicians out there in the community become more aware of what the treatment strategies are, things like the new update in the guidelines.
I am not sure how long that will take for that to permeate into the practice, so it does need active dissemination, better access to diagnostics and more empowerment to practitioners to be debating with patients what their final choices are.
Ruschitzka: At the beginning around 20 minutes ago about what we do in the clinics, it gets somehow lost to the GP but you are sometimes not referring to us. How can we close this gap? What can we do better, because ultimately this pandemic of heart failure, we can only tackle together and we need the help of our friends in GP practices, internists, most of them will see our heart failure patients?
What can we do to close that gap, that you send them and that more patients out there get the life-saving therapy? Richard – you. Jill, Tiny?
Riley: If I can just bring in a different perspective. It is more than just us that are doing that and it’s part of raising public awareness of heart failure and public empowerment or patient empowerment, whatever we want to talk about, which is actually saying ‘I think I might have the symptoms, what should I be doing?’
I don’t think it just is resting on our shoulders. Of course there is our responsibility, but we need to think much wider about it.
Hobbs: Yes, less passivity. We talked about that at the start; an expectation that even if you have multi-morbidity there are things that you can do that make for a more useful life and of course it’s incredibly important for health systems as well because in this disease or in this syndrome, the thing we are really trying to prevent is progression that results in repeated hospital admissions.
Pieske: Yes, heart failure, we can prevent it and we can treat it. That’s a message. Unfortunately the words ‘heart failure’ includes the word ‘failure’, but we are getting better and I said that at the guidelines yesterday as well; name me any other specialty in medicine that offers you even more life-saving therapies and all the symptom-improving therapies that come with it.
To this end we have started a huge awareness programme now from the Heart Failure Association and we all need your help on that. The awareness is not there – that is a very good point, Jill.
Hobbs: I think you asked why there is less referral than there should be. Making more clear guidance about what the decisions are that would result in a referral, so for example making the diagnosis more certain is an important reason to refer.
When patients are stable, actually assessing function and re-referring if the syndrome is changing. We don’t currently have the evidence, but almost certainly we will be monitoring more than we are doing.
Ruschitzka: Can I kick in right there? That’s an important take-home and we come to that in a second for me. How I see this drug, LCZ is not a drug that kicks my acute decompensated heart failure out of bed, who is New York Heart IV, heavily congested; that’s not the right patient.
For me it’s a New York Heart II, III patient who is symptomatic in whom I am very confident that with this drug this patient can live a year longer and a lot better and make a symptomatic patient stable for more. This is a patient where I feel sometimes my GPs in the Canton of Zurich, they think ‘Oh, he’s stable, he’s not fine but why should I refer?’ because these are the patients, if we refer them and put them on LCZ, they have a life that is a year-and-a-half longer probably and most importantly also, they feel better.
We have only now five minutes.
Jaarsma: If we only have five minutes we have the multidisciplinary team, because I would really still break another few whatever you say to include the multidisciplinary approach and to see the challenge now to work with nurses that can help the patients to accept the change in drugs, but also like Burkert, he went to the patient and took out the ACE inhibitor from the pill box.
I don’t think you will do that with all the patients, so we need to have a good strategy in place that we educate our patients what to report, when to report and to change the drugs and not keep them somewhere in a box for safety. I would really make a point that if you don’t have multidisciplinary heart failure clinics now, just start it tomorrow.
Ruschitzka: What’s your trick for increasing adherence? What’s your best trick? Tell us!
Jaarsma: My best trick is to be very honest and ask patients and say ‘Some people don’t take their drugs daily. How is it with you?’ and to open that, that other people do that, you might be open to me and say ‘I understand that’, and if they don’t take it, then it is the end of the discussion.
Pieske: One last comment from my side. I completely support this notion. I think in Germany we do a poor job here because we do not have the heart failure nurse available on the larger scale. There are some hotspots, but on the larger scale, no heart failure nurses and the network and the integrated management for heart failure is not very well developed.
I see this every day and as you said, the patient needs to understand he has a deadly disease, he has to understand what type of medication he gets, why he gets it, what could be the potential side effects, how to deal with it. I cannot provide this. I can provide it once when I see the patient in an acute setting but then I have to transfer him to someone with whom I cooperate on a regular basis and we have to build that network.
The second point I want to make is we have to build quality measures for these patients. Say for example we did a review in our institution how many patients received an ICD when in the echo lab the ejection fraction was below 30%. It was one third of them, they had an ICD and one third of them just went without any further evaluation. They come from orthopaedics and I am sure we will face the same problem here now with implementing new therapies. The gap with the guideline programme in the US is a good one. I would want a system in Germany where if we did something not optimal, then the reimbursement is under question and we have to be urged to be better here.
Ruschitzka: The multidisciplinary management is a key issue for the Centre of Excellence initiative that we are going to launch together with the ESC in heart failure all over Europe. This is key that we find this. We are not always as lucky as you are in Scandinavia or in England where you have these multidisciplinary teams.
The reason why we put that in and wanted to discuss with you was to show how important it is for the patient that we work together in teams, bring the different specialties in, connect and particularly the heart failure nurses. That is something in some countries is not existing as much as particularly in your countries and work closer with the GPs, the referring physician, the internist, that is something which we have to further improve. That’s a key feature of the Centre of Excellence initiatives. We will have that on different levels all over Europe and it is going to be launched very soon.
We have just two minutes for take-home. I ask that it’s not that Michele and I will do it – everyone has one. Why don’t we start with the ladies, first? We sometimes cut them out. You go with your take-home; what is a tip and trick you want to give all of us in terms of multidisciplinary management and also related to implementing new therapies like LCZ?
Riley: The tip I would give is, and you’ve talked about it, about changing medication, about patient uncertainty, etc, my tip is to have a telephone helpline, you have it available 24 hours, even though you may man it only in working hours but it enables a patient to leave a message and get an answer rather than waiting for a clinic visit or a follow-up visit.
Jaarsma: My tip is for clinics that have a multidisciplinary team to go back home and say ‘This is now what we have to implement, new guidelines, new treatment. How are we going to do this?’, so revisit the clinic and those who do not have the clinic to just mail us and say ‘How can we start a clinic?’ and we can help.
Pieske: My tip, and this is what I also want from my people in our department, is that when we put a patient on a new medication and we let him go I want a very clear plan for the next steps – when, what and what to do in a certain situation, so to make sure that what we started is really then continued and further implemented. Just mentioning in the dismissal letter ‘Please up-titrate’ is not enough. You have to be very specific here and maybe even call.
Senni: I think that we have a great opportunity now to monitor the daily activity. We are thinking about mortality, we are thinking about hospitalisation. Now I think with the ageing population we have to move forward to look more in-depth at the quality of life, to look more at the daily activity.
We need that these people live better, enjoy their lives and therefore maybe the future will be to use some simple device like this using the accelerometry to see how they are doing because it is something that everyone has and we can understand more what we are doing really.
Ruschitzka: Heart failure is clearly a team work also, that’s why we put this together, that we all encourage you to establish multidisciplinary teams when it’s possible. It’s a long way. It got a 1A recommendation in the guidelines, it’s a long way to go. We are working on that but our patients will benefit. They will not only benefit from the spectacular new drugs and the devices we have but also having a good doctor and a good nurse taking care of them, being available for them, talking to them and being reachable in a way.
That’s very key and I truly enjoyed this here today and I give the last word to Michele, to my co-Chair and I really tremendously enjoyed this symposium.
Senni: It was a great symposium. It was really interactive and we learned a lot from these people, so thank you very much, I really enjoyed and countries such as Italy have to learn more how to improve the quality of life, how to work with these people that are very involved and they can teach us a lot of things. Thank you very much. [Applause]
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