Optimizing Barostim Outcomes: Practical Approaches to Patient Selection and Monitoring

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Ms. Bither: 
Medical devices play an important role in improving the quality of life and overall symptom relief for our patients with heart failure with reduced ejection fraction, or HFrEF. Today, we're going to explore best practices for communicating with patients about their quality of life for successfully identifying appropriate candidates for treatment with Barostim.

This is CME on ReachMD, and I'm Cindy Bither.

Ms. Wallace: 
And I'm Andrea Wallace.

Ms. Bither: 
In HFrEF, adverse autonomic nervous system activation plays an important role in disease progression. Barostim is an implantable pulse generator that delivers continuous electrical stimulation of carotid baroreceptors through a lead sutured on the carotid sinus. It works to reduce heart failure symptoms by modulating baroreceptor nerve activity and restoring baroreflex sensitivity, which rebalances systemic autonomic control systems.

So as one of the first steps to treatment with Barostim in our clinics, we work to identify which patients may be good candidates.

Andrea, as a healthcare team member who is a direct point of contact with patients, and oftentimes their most frequent point of contact, can you talk a little bit about how you do this in your practice?

Ms. Wallace: 
Sure, Cindy. Advanced practice providers and nurses are a large portion of the healthcare system and spend most of their time in direct patient care roles. This makes them key stakeholders in facilitating discussions regarding heart failure treatment options. In large part, these discussions are prompted because we are experts at eliciting symptoms from patients and having quality of life discussions with them.

In addition to that, getting a full picture regarding the impact that heart failure has and its symptoms and burden on people's quality of life is important for improving their overall health and well-being.

Communication with patients is important in determining symptom severity. For that, I've actually streamlined my approach in eliciting these symptoms and have very specific questions and flow in which I ask that. Such as, how does your activity compare 1 or 2 years ago to today? Are you able to complete your grocery shopping without using a motorized cart? Do you have to take rest breaks? How did you do walking in clinic today? Did you take any rest breaks coming in? Were you fatigued? Or were you short of breath?

This is also an important time to involve the family and their care team, because sometimes patients are not as honest or realize the depth of their symptoms and how they've progressed. So I ask family members often as well, how do you feel that their activity is compared to a year ago? Are they keeping up with family activities, such as outings, going to a baseball field, a baseball game, keeping up with grandkids? Are they able to help you around the house with daily activities?

Ms. Bither: 
So staging patients and appropriate patient identification and selection for Barostim is very important. Andrea talked a bit about who may be a candidate as to how she elicits symptoms from her patients.

And so we have to pay attention to those people who have especially been recently admitted for a heart failure exacerbation or someone who we've had to adjust their diuretics, or they've been complaining of worse symptoms, and that includes a full workup.

And then we have to start talking about shared decision-making with the patient to figure out whether or not we're going to offer them Barostim and to see whether or not they would be interested in this device. And a lot of the times that really is us talking to the patient to figure out exactly what do they understand about what's going on, and what do they understand about what the future will hold for them if their heart failure continues to progress.

And so with that, if once they have really understood that things are not good and they're progressing, then we can talk about the workup. And that initial workup to help figure out whether or not they would be a candidate, is to get some blood work, including an NT-proBNP, and a carotid ultrasound, actually for measurements, not to see if it's patent, but to actually measure the anatomy and the vasculature of the neck to make sure that they're suitable for implantation.

And so a lot of times, once we've gotten the patient to understand that the way they're progressing, if they want to avoid or at least prolong their time where they do not have to be looked at for things like transplant and LVAD, then the time to act is now.

Identifying and selecting patients is the first step. So now we need to talk to them about their expectations and their goals for treatment. In the BeAT-HF clinical trial, Barostim plus guideline-directed medical therapy, or GDMT, resulted in clinically meaningful improvements in exercise capacity and quality of life for patients with HFrEF.

Andrea, how do you talk to your patients about the potential impact of treatment of this device on their quality of life? And how do you help set expectations and let patients know what to expect post implant?

Ms. Wallace: 
I do discuss with the patients the benefits of guideline-directed medical therapy and that they do have to continue these medications. Barostim does not replace the medications. This is in addition to.

Then I explain, once all the medications are on board, if the patient doesn't feel better, I start thinking, what is next? How can I improve quality of life for the patient? How can I help them improve their walking distance? How can I decrease their shortness of breath? That's where cardiac devices such as Barostim come in.

I do take the time to explain the Barostim device tricks the body in waking up, if you will, or stimulating the parasympathetic nervous system, which affects how the heart functions. By doing this, we can improve symptoms of heart failure, such as activity intolerance, shortness of breath, and quality of life. I explain briefly that it is a surgical procedure. They'll meet with a surgeon and get an in-depth discussion regarding the risk and benefits of the procedure.

Then I go on to talk about the post-implant follow-up and treatment. I'll let the patient know that we'll be seeing them every 2 to 3 weeks in clinic for about 8 weeks to get them fully titrated to a therapeutic stimulation zone. Additionally, I'll tell them that I will be seeing them in clinic alongside their titration so that I can assess for medications, because it's important at this time to realize at about week 2 to 4, you need to really look at their diuretic doses and maybe de-escalate that.

Ms. Bither:
I think, in addition to this, when I think about these patients, that we have to consider whether or not the patient is too sick for the device, and so therefore I start looking at their end-organ function. If their end-organ function is stable, I again try to utilize the fact that I'm trying to prolong their time before they need to be looked at for more advanced therapies. But setting the expectation that this may not make them feel normal, but we hope to at least make them feel better and that they can do more.

And I also think that in the post-op time, that they need to understand that this doesn't mean that we won't be seeing them as often. They still will be coming to clinic, just like she said, every few weeks, and that this is still going to be a team effort between our teams and the patient and their family to try to get the patient through this and to prolong their lifespan.

This has certainly been an enlightening conversation, but before we wrap up, Andrea, what's your one take-home message for our audience?

Ms. Wallace: 
My final take-home is that nurses and advanced practice providers are critical in the selection of Barostim candidates. Because of their relationships and time spent with patients, they're actually very good at eliciting symptoms and assessment skills and really getting information out of patients in a change in quality of life since last visit or over the last year. Additionally, once implanted with Barostim, I believe that advanced practice providers are well suited to be the driver of titration visits, program design, and also program growth.

Ms. Bither: 
And I think my final take-home message is that we're not going to find the patients unless we're actively looking for them. So it has to be something that we put on our radar with every patient that we see in clinic that has not reached optimal guideline therapy, that is still having symptoms, and that potentially may not be a candidate for any advanced therapies, and so we need to pull out every stop that we can to help prolong their life and preserve their end-organ function.

That's all we have time for today. So I want to thank our audience for listening in and thank you, Andrea, for joining me and for sharing all of your valuable insights. It was great speaking with you today.

Ms. Wallace: 
Thank you, Cindy. Very good discussion.

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