Heart failure management is shifting as pharmacists take on a larger role in identifying and treating patients with the condition. At a recent forum in Phoenix, Craig Beavers, a cardiovascular clinical pharmacist, led a discussion on the evolving clinical setting for heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).
HFpEF accounts for more than half of all heart failure cases. The forum highlighted a growing disparity between the two main types of heart failure. While HFrEF has seen progress due to better management of ischemic drivers, HFpEF—defined as an ejection fraction below 40%—is becoming the dominant phenotype. This shift is largely driven by an aging population and the rise of comorbidities like obesity, hypertension, and diabetes.
Despite advances in therapy, the lifetime risk of heart failure remains high, affecting 6.7 million people in the United States and 56 million globally. HFpEF carries a particularly high economic burden due to increased outpatient utilization and higher pharmacy costs. Beavers noted that the condition is frequently misdiagnosed or “glossed over” in primary care settings, where symptoms like shortness of breath are often attributed to pneumonia, obesity, or aging rather than heart failure.
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Newer treatments show faster benefits than traditional options
The pharmacotherapeutic discussion focused on mineralocorticoid receptor antagonists (MRAs), specifically comparing finerenone with the traditional steroidal drug spironolactone. Beavers presented data from the FINEARTS-HF trial and the older TOPCAT study, noting a key difference in how quickly benefits appear. Finerenone demonstrated a divergence in benefit in as little as 28 days, whereas TOPCAT’s American subgroup analysis suggested a benefit at approximately 248 days.
Beavers argued that starting treatment during hospitalization or within the first seven days yields the most dramatic results. While hyperkalemia is a concern for clinicians, participants argued that the risk of the disease often outweighs the risk of the medication. “Realistically…potassium doesn’t kill people in these trials; the heart failure does,” Beavers said, adding that finerenone has shown a more balanced safety profile regarding potassium levels compared to spironolactone.
Even when the clinical data supports a specific medication, real-world barriers frequently prevent optimal care. Participants noted that in large health systems, pharmacists often work in “silos.” An inpatient team may initiate a branded medication like finerenone, but the patient often faces a high co-pay or a rejected prior authorization when they arrive at their local pharmacy.
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The hospital and emergency department are not the places where you optimize chronic disease pharmacotherapy, one attendee noted. Without a solid transition-of-care plan, patients frequently fall through the cracks. Common breakdowns occur when prior authorizations are sent to technicians who may lack the training to interpret echocardiograms or clinical markers like hemoglobin A1C, leaving patients without the necessary treatment.
Pharmacists are increasingly using population health reports in electronic health record systems to identify patients with low ejection fractions who are not on optimized therapies. Some participants discussed using “heart failure navigators” who act as a patient’s advocate through the process. These professionals, often pharmacists or nurses, run reports to find hospitalized patients and ensure they are connected to resources and follow-up appointments within seven days. As collaborative practice agreements expand, the profession is moving toward independent titration and management of heart failure, similar to models used for diabetes and hypertension.