Heart Failure Pharmacotherapies

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Geralyn Warfield (host): Welcome to today's podcast where we're talking to Kim Cuomo about heart failure pharmacotherapies. Kim, would you like to tell us a little bit about yourself before we dive into the content?  

Kim Cuomo (guest): Well, sure. Well, thank you for having me today. I am an adult nurse practitioner. I work within Johns Hopkins University Department of Medicine in the Division of Cardiology. I've been working with heart failure patients for the past 17 years and helped really grow our heart failure bridge clinic, which is a program that reduces hospitalizations in heart failure patients within our institution. 

Geralyn Warfield (host): Well, it sounds like you've got a lot of expertise to share with us today, and we're really looking forward to talking with you. So, I’m going to dive into my first [00:01:00] question, which is, tell us a little bit about the importance of optical medical therapy in heart failure. You obviously have seen quite a few patients, So, how does this apply?  

Kim Cuomo (guest): So, it is incredibly important that we get patients who have heart failure with reduced ejection fraction on optimal medical therapy. So, over the years we've had, we know that there are at least four medications that reduce mortality in heart failure patients. Those medications are ACE inhibitors or ARB or angiotensin receptor neprilysin inhibitors. 

The other class is beta blockers; the third class is MRAs, and then the fourth class would be the newest on the block, which is our SGLT2 inhibitors. We know that utilizing these medications—all four of them—improves mortality in patients with heart failure with reduced ejection fraction. Without any of these medications, patients’ 2-year survival, 2-year mortality is somewhere along [00:02:00] 35%. 

If we add all four of these agents on, we can reduce that to somewhere less than 10%. So, it's very important that patients are on these medications.  

Geralyn Warfield (host): So, thinking about clinical practice and our listeners, there are a lot of medications that some of these heart failure patients are taking. How would you go about describing to the patients the importance of taking the full complement that they are actually prescribed? 

Kim Cuomo (guest): Some patients don’t like that we continue to add medication. Some are actually really offended, or don't want to take it, or [are] upset that we continue to add medicines. I think it's really important on the clinician side to explain exactly why we're adding these medications to the patients in as simple terms as possible. 

It's oftentimes really good to use an analogy of some sort as we are adding medications to patient’s regimen. And to, to get their buy-in, one of the physicians that I work with likes to use a football analogy. He calls the four medications “the lineman” essentially, and those [00:03:00] medications are important to protect the patient who is the quarterback. 

So, having some type of analogy, whether it's a football or something, something else that the patient can relate to, I think, is important to get their buy-in.  

Geralyn Warfield (host): I think that's a great analogy. It wouldn't necessarily work for all patients, but even those of us that aren't quite the sports fans, that some of the rest of our listeners are, totally understand the need for all of those linemen to protect that patient. 

Kim Cuomo (guest): Exactly.  

Geralyn Warfield (host): That's a great, great example. So, moving in a slightly different direction with my questions, obviously sometimes there are barriers to getting patients on these medications, and as a result, then we fail to have optimal therapies, fail, fail to have the best outcomes we can have for our patients. So, could you talk a little bit more about that and how it applies?  

Kim Cuomo (guest): Sure. And this happens every day. Every heart failure patient is unique and has different needs and co-morbidities, different insurance plans, different socioeconomic barriers. So, [00:04:00] as clinicians, we need to take all of that into account when we are trying to get patients on the right therapies.  

It takes a village. It takes myself, it takes the wonderful nurses that I work with, our pharmacists, social workers, close management or close ties with a nutritionist, to make sure the patient's diet is, is optimized. It really takes a village to get these patients on the medicines. 

Oftentimes we are spending a fair amount of time, getting prior authorizations approved. And then sometimes even working directly with the manufacturers to getting the patients through a patient assistance program to get them the medications. There are ways of getting these medicines; we shouldn't give up. 

If, for some reason, we've gone through every channel and avenue to get a patient a medication it's just not feasible, then we have to document that, and make sure that it's a really good reason that the patient isn't on the medicine.  

Geralyn Warfield (host): Wow. You've given us a lot to think [00:05:00] about. We're going to take a brief break and then we'll be back to talk a little bit more about heart failure pharmacotherapies.  

Geralyn Warfield (host): Welcome back. We're here with Kim Cuomo talking about heart failure pharmacotherapies and the complexity of the types of medications that can be used, and the importance of a team to get those medications to the patients that need those. And I'd like you, if you could, to talk just a little bit further about the role of APPs and RNs on increasing the compliance with heart failure therapy, because as you described earlier, it's sometimes very frustrating for the patients to have to take a myriad of medicines, to be asked to take even more medications. And I suspect for some of them, they feel like they failed. And the reason they have to take even more is because they're not doing their job, or they get mad at their body because their body's not doing the job that it's supposed to. So, how can we help these patients more? 

Kim Cuomo (guest): Sure. So, I think it really, it takes getting a good relationship with a patient, getting a rapport with a patient, and [00:06:00] that's really where APPs and nurses come in to play. By no fault of physicians, they tend to not have as much time to spend with patients to really go over why we're doing what we're doing in terms of their heart failure management. 

In addition, most heart failure programs and clinics are staffed by nurse practitioners, PAs, and nurses. And so, I think we are at the forefront of heart failure management. And we have the time to spend with patients and we're willing to put that time and effort in to getting these patients on the right medicines, getting the buy-in as to why we're doing what we're doing, which in turn has helped keep patients out of the hospital and improve symptom management. 

Geralyn Warfield (host): Those are all great ideas. And I'm wondering if you have any resources that you might suggest that if a nurse, a nurse practitioner or somebody else in the practice has questions about anything that we've talked about today, are there places that you would go for information that you could recommend? 

Kim Cuomo (guest): So, I know that through our institution, Johns Hopkins, that we do have a website [00:07:00] dedicated to heart failure. And I would encourage anyone to reach out and to look on our website for any information. Through that, you'll be able to see our variety of nurse practitioners who treat these patients. 

And I'm sure I speak for all of our nurse practitioners that if anyone ever had a question, or wanted to know how we do things to do not hesitate, to reach out to us. 

Geralyn Warfield (host): Well, we're really grateful that you are now part of our team as we're caring for these heart failure patients. Thank you so very much for taking time to be with us today and share your expertise and give us some pearls of wisdom that we can apply in clinical practice. 

We've been speaking with Kim Cuomo about heart failure pharmacotherapies. This is Geralyn Warfield, your host, and we'll see you next time. 

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