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Dr. McDonough: 
A key aspect to optimize management of heart failure is building effective communication with patients. Are you up to the task? This is CME on ReachMD, and I'm Dr. Brian McDonough. Joining me to discuss building effective communication about heart failure are Dr. Barry Greenberg and Dr. Melissa Mclenon. Thank you both for joining us.

Dr. Greenberg: 
Nice to be here with you.

Dr. Mclenon: 
Thank you so much for this opportunity.

Dr. McDonough:
We know that identifying the correct pharmacologic treatment strategy for patients with early heart failure is important, it's only half the battle. Sometimes the more challenging aspect is getting the patient to buy into the strategy. Dr. Greenberg, can you please speak to this issue?

Dr. Greenberg: 
Yeah, I think this is really a critical issue, and you’ve framed it really nicely. If you think about it, we know that inadequate self-care is associated with hospital readmission and is a very potent marker for poor health outcomes. We also know that a lot of the acute hospitalizations that we see, both the initial admissions and the readmissions, are due to insufficient medical management, poor patient treatment plan adherence, and lack of appropriate follow-up. And those are targets that we can hone in on to try to really improve outcomes and quality of life in our patients. The way we do that is trying to optimize patient knowledge, education, and counseling, to increase self-care and medication adherence. This is not something that one person is going to be able to do alone; this really almost begs for multidisciplinary care.

Dr. McDonough: 
Dr. Mclenon, if I could turn to you, you're on the front line of this alongside Dr. Greenberg, so can you talk a little bit about the challenges and strategies to engage patients from your perspective?

Dr. Mclenon: 
Yes, it can definitely be challenging, especially when you're talking about such an array of medications. These patients take multiple medications a day with a variety of side effects. So medication compliance is key for these patients. Non-compliance is the number one reason for their readmissions. We really got to work with the team. It's inpatient, outpatient, on all the clinics, it’s the nursing at the bedside, the cardiologist, dietician, even the social worker. So a multidisciplinary approach is critical.

Dr. McDonough: 
Thank you for sharing your perspectives. And now the New York Heart Association Functional Classification categorizes patients according to their functional capacities. So how does a patient classification affect your treatment plan, Dr. Greenberg?

Dr. Greenberg: 
Well, let me go over the NYHA classification first. And class I is the absence of any symptoms; class II would be a slight limitation on physical activity; class III, when ordinary physical activity is limited because of symptoms; and then class IV, patients are unable to perform any physical activities without discomfort.

This really tells me when a patient relates their symptoms and puts it into the perspective of their everyday life, how they're dealing with heart failure and what their limitations are. Often, they'll express with their class III or IV a lot of frustration and the desire to feel better so that they can do more. It's also a way of communicating amongst healthcare providers about the status of the patient. In a way, it's the lingua franca that we use to describe patients to one another. And then finally, in our guidelines, there are recommendations that are specific, according to NYHA Functional Classification for utilization of some of the approaches that we have and the strategies that we use.

Dr. McDonough: 
Dr. Mclenon, what might you add to what Dr. Greenberg just said?

Dr. Mclenon: 
Yes, I think it's critical to really treat not only the diagnosis but also their symptoms. Patients who are end-stage heart failure, you know, their ultimate option really ends up in the transplant or advanced therapies of some sort. So to prevent them from getting there and to extend their life without the needs for this end-stage heart failure management, then optimizing their medications is critical.

Dr. McDonough: 
Now, we see there are three key aspects to addressing the patient's issues and engaging the patient in the treatment strategy. So Dr. Greenberg, could you start the discussion by talking about medication reconciliation?

Dr. Greenberg: 
Yeah, I think that providers need to be good sleuths and determine, after they've got patients on good guideline-directed medical therapy, whether or not they're actually taking the medications. And sometimes in clinic, we'll actually go back and look at their refill history and find that a patient who's been on a good regimen, haven't had some of their medications refilled for the past 6 months. So I think it's really important to educate patients and discuss with them the long-term benefits of guideline-directed medical therapy.

I think patient education and counseling is also critical. Timing of the medications, making sure that you're not overlapping drugs that have complementary side effects, for instance, drugs that lower blood pressure, separate them by a couple of hours. Some of the medications are better tolerated when you take them with meals, some other medications you need to avoid taking with meals. Understanding that and making sure the patients are clear on that is really critical.

And then finally, going over patient expectations. We need patients to understand that these medications were given based on the results of well-done clinical trials showing unequivocal evidence of benefits, and that there is a risk, if they stop these medications, they're going to do less well, and that could happen quickly.

Dr. McDonough: 
And if we turn to you one last time before we close, Dr. Mclenon, how might you offer patient education and counseling and help ensure he has realistic expectations?

Dr. Mclenon: 
I think that patient education with our heart failure pharmacists by our side is critical. We have pharmacists that also can help discuss the timing and things with meds and continue to reinforce that with the patients in clinic.

The other thing I would want to talk to the patient about is, what are some of their reasons why they really want to stop some of the medications? Is it a cost issue? Is it a fact that the timing is not good for them because of a work schedule or going to bed early for the kids? Whatever it may be, find out what their challenges are with the medications, to really understand their perspective and see how we can guide them and counsel them in that area. If we can take a med that's three times a day and adjust it to twice a day or increase the once-a-day dose, however we can adjust it to make it more beneficial for them as far as their practical social life, as well as the benefits on the heart failure.

Dr. McDonough: 
This was a wonderful discussion. Is there anything else either of you would like to add? Dr. Greenberg, care to start us off?

Dr. Greenberg: 
I think the one pearl that I'd like to leave the audience with is that we really need to consider patient management a partnership between the healthcare team and the patient, and I think that's really what we've been aiming for and what we discussed today.

Dr. McDonough: 
Thanks, Dr. Greenberg. And I'll give the final word to you, Dr. Mclenon.

Dr. Mclenon: 
Thank you. Yes, I absolutely agree with Dr. Greenberg. And just keep patients engaged in these conversations. You really want to know – you want to talk about these things in clinic when you see them, to really know what their concerns are about the medications.

Dr. McDonough: 
That's a great way to round out our discussion on building effective communication about heart failure. I want to thank my guests, Dr. Barry Greenberg and Dr. Melissa Mclenon. It was great speaking with both of you today.

Dr. Mclenon: 
Thank you.

Dr. Greenberg:
Thank you.

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