Multidisciplinary cardiac case conference overcomes therapeutic inertia in heart failure: achieving guideline-directed therapy in high-risk populations

Background/Introduction

Therapeutic inertia remains a major barrier to guideline-directed medical therapy (GDMT) in heart failure (HF) with reduced ejection fraction (HFrEF). Patients with advanced chronic kidney disease (CKD), frailty, and established HF are often undertreated. We evaluated whether a multidisciplinary cardiac case conference (MDCC), implemented alongside standard care, could overcome these barriers.

Purpose

To assess GDMT optimisation, left ventricular (LV) recovery, and safety outcomes of an MDCC for HFrEF, with subgroup analyses by renal function, frailty, and HF duration.

Methods

Over 24 months, 213 patients were referred to a weekly MDCC with 335 reviews conducted. This analysis focuses on consecutive HFrEF patients (n=89) referred for medication optimisation (February 2023-January 2025). The MDCC comprised structured nurse practitioner case presentation, pharmacist review and Heart Failure Specialist input, alongside routine care. Primary outcomes included quadruple therapy achievement and LV ejection fraction (LVEF) change. Subgroup analyses were undertaken by baseline estimated glomerular filtration rate (eGFR), frailty, and HF duration.

Results

The cohort included high-risk patients: 44% CKD stage ≥3 (6% eGFR <30), 28% frail, 30% HF <2 months duration, mean age 64±16 years, baseline LVEF 30% (IQR 20-35%). Median 2 MDCC reviews (range 1-9).

GDMT: Quadruple therapy increased from 45% to 82% (p<0.001). RAAS inhibition (ACE/ARB/ARNI) 90% to 99%, of those angiotensin receptor-neprilysin inhibitor: 36% to 63%; mineralocorticoid receptor antagonist: 64% to 89%; sodium-glucose cotransporter-2 inhibitor: 67 to 94%; beta-blocker: 94% to 98%.

LV Recovery: Mean LVEF improved +12.1±10.8% (p<0.001); 66% improved LVEF category; 37% achieved recovered LVEF ≥50%.

HF Duration: Patients with HF for two to five months showed greatest recovery (56% achieved LVEF ≥50%) versus ≥12 months (29%), highlighting a window of opportunity in patients with "stable" disease often overlooked for intensification.

Safety: Patients with eGFR <45 (n=27) had stable renal function (GFR +0.3, p=0.87) and 74% achieved quadruple therapy. Frail patients achieved similar LVEF improvement (+11.0% vs +12.4%, p=0.61). There was no significant change in hyperkalaemia, renal dysfunction nor admissions related to medication side effects.

Clinical Outcomes: One-year HF hospitalisation 6.7%; mortality 4.5%; loop diuretic use decreased from 47% to 20%.

Conclusions

An MDCC achieved 82% quadruple therapy and significant LV recovery. Patients with CKD, frailty, and established HF achieved safe optimisation. The two-to-five-month HF duration group showed greatest recovery, supporting structured early intervention, in keeping with the STRONG-HF trial. An MDCC for heart failure patients overcomes therapeutic inertia, and is efficient and cost-effective with clinical improvements for HF patients regardless of comorbidities.Figure 2 LVEF Flow ChartFigure 1 GDMT Bar Graph