Simultaneous or rapid sequence initiation of medical therapies for heart failure: seeking to avoid the case of ‘too little, too late’

Abstract

Similar to many cancers, a new diagnosis of heart failure (HF) in routine clinical practice continues to carry a roughly 50% chance of death within the next 5 years.1,2 However, commonalities in prognosis notwithstanding, the culture and approach to therapy for cancer and HF remain remarkably different. In the setting of active or progressive disease, oncologists and cancer patients are often aggressive in decisions to initiate or change chemotherapy, even in the absence of new or worsening symptoms. This sense of urgency is the norm in cancer care, readily accepted by cancer patients and clinicians, and maintained by keen awareness of the benefits of therapy and the risk of no therapy. By comparison, the culture of care for HF with reduced ejection fraction (HFrEF) does not include this same sense of therapeutic urgency. Instead, despite robust clinical trial evidence and strong guideline recommendations, there remains a strong culture of hesitancy towards initiating and titrating lifesaving medications among eligible patients. Clinical risk is frequently underappreciated, and stable symptoms are often misconstrued as ‘low risk’ and as justification for not making an indicated change in therapy.3,4 As a consequence, many eligible patients with HFrEF never receive therapies proven to extend survival, receive them with significant delay, or receive them at perpetually low doses.3,5 Moreover, when medication changes are made, there is often prolonged sequencing of beneficial therapies. It can take several months to a year using this ‘one medication change at a time’ approach before patients achieve target or maximally tolerated doses of guideline-directed medical therapy (GDMT), and at each step, the culture of clinical inertia must again be overcome (Figure 1).6