The Perfect Storm: Barriers to Heart Failure Treatment Optimization.

Despite advances in heart failure therapies with proven positive outcomes, treatment gaps in clinical practice persist and heart failure morbidity and mortality remain high. The lack of treatment intensification to evidence-based targets accounts for a significant portion of unattained treatment goals and has been characterized to involve 3 main elements: the provider initiating and titrating the medication(s), the patient themselves, and the system that serves as the gatekeeper and facilitator for health care needs. This article will examine the mechanisms and impact of these 3 factors, and present targeted initiatives to help improve patient outcomes and quality of care.

Managing the infected heart.

Most infective processes are straightforward and can be diagnosed from bacterial findings in a single test. IE does not always follow this tenet, so establishing the diagnosis can be difficult. The salient features of IE may present atypically or be obscured by the presence of preexisting and coexisting diseases. Flulike symptoms may mask the beginning of this devastating disease. Early diagnosis of IE is important because of its high risk of morbidity and mortality. Management of the patient who has IE is complex and requires interventions by infectious disease specialists, cardiologists, respiratory therapists, and critical care nurses to address the many multifaceted complications. Early evaluation, diagnostic validation, multidisciplinary management, prompt pharmaceutical initiation, and intense critical care nursing intervention are necessary to reduce the probability of long-standing complications and to improve patient outcomes.

Improving heart failure patient outcomes utilizing guideline-directed therapy.

Heart failure (HF) prevalence continues to rise and remains a significant burden to patients, caregivers, providers, and the healthcare system. Guideline-directed medical therapy with standard neurohormonal blockade has been the cornerstone of medical management for many years. Despite aggressive utilization of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists, HF hospitalizations and readmissions are common and residual mortality remains high. With the development of two novel medical therapies (sacubitril/valsartan and ivabradine), the American College of Cardiology, American Heart Association, and Heart Failure Society of America released a pharmacologic update to provide guidelines for incorporation of these agents into clinical practice. Although effective via different mechanisms of action, both agents now have a prominent role in risk reduction. HF medical regimens often become quite complex, especially when associated with comorbid conditions, and require frequent follow-up. Providers must be proficient in patient monitoring, medication dose titration, and therapy optimization. Individualized patient care strategies such as guideline-directed therapy can promote long-term adherence and quality of life.

Immune system modulation in the highly sensitized transplant candidate.

Heart transplantation can be a lifesaving option for patients with end-stage heart failure. However, implanting recipients with an organ or tissue from a donor presents immunologic challenges. Sensitized recipients are at risk for hyperacute rejection because of the presence of preformed antibodies. Immune modulation with cyclophosphamide, plasmapheresis, and intravenous gamma globulin are methods used to desensitize transplant candidates with preformed anti-HLA antibodies to achieve successful transplantation.