WEBVTT

00:00:00.299 --> 00:00:02.773
For our last case, Teresa is going home with a

00:00:02.816 --> 00:00:06.656
changed treatment plan. Teresa is home after a hospitalization for

00:00:06.699 --> 00:00:10.321
worsening heart failure. Her discharge list includes medication changes.

00:00:10.615 --> 00:00:13.303
A cardiology visit is planned, but she does not know

00:00:13.388 --> 00:00:15.159
who will review her next blood test.

00:00:15.692 --> 00:00:20.074
Clinical context. Confirmed heart failure with preserved ejection fraction; left

00:00:20.244 --> 00:00:24.255
ventricular ejection fraction 55 percent; chronic kidney disease and type

00:00:24.255 --> 00:00:26.806
2 diabetes. At the stable follow-up.

00:00:27.096 --> 00:00:29.997
E G F R 42 milliliters per minute per one

00:00:30.082 --> 00:00:35.010
point seven three square meters; potassium 4.7 milliequivalents per liter.

00:00:35.314 --> 00:00:39.610
Current task. Reconcile therapy and assess eligibility and safety before

00:00:39.823 --> 00:00:42.472
adding a mineralocorticoid receptor antagonist.

00:00:42.776 --> 00:00:46.574
Coordination gap. Laboratory date and responsible result reviewer are not

00:00:46.617 --> 00:00:49.312
documented. Reconstruct what is happening at home.

00:00:49.575 --> 00:00:51.943
Ask Teresa to bring the medicines she is actually taking,

00:00:52.135 --> 00:00:54.481
or review them by a reliable remote method.

00:00:54.908 --> 00:00:58.620
Compare the hospital list, the outpatient record, pharmacy information when

00:00:58.706 --> 00:01:03.414
available and her account. Resolve duplicate therapies, stopped medicines that

00:01:03.456 --> 00:01:06.315
remain in the record and prescriptions that were never filled.

00:01:06.656 --> 00:01:10.283
Ask about supplements, salt substitutes and nonprescription agents as part

00:01:10.326 --> 00:01:12.858
of the safety review. Do not interpret a missed dose

00:01:13.072 --> 00:01:15.141
as lack of interest without asking why.

00:01:15.504 --> 00:01:21.221
Cost, transportation, language, vision, manual dexterity and unclear instructions may

00:01:21.264 --> 00:01:24.440
all affect the plan. If the medicine is unaffordable, record

00:01:24.696 --> 00:01:26.915
the barrier and the action needed to address it.

00:01:27.171 --> 00:01:30.200
A plan that depends on a nonexistent supply is not

00:01:30.285 --> 00:01:35.009
an implemented treatment. Review symptoms, volume status, blood pressure and

00:01:35.052 --> 00:01:36.524
the trajectory of kidney function.

00:01:36.929 --> 00:01:39.745
The decision to add treatment must consider stability and the

00:01:39.788 --> 00:01:43.822
existing regimen. This fictional stable follow-up is an opportunity to

00:01:43.864 --> 00:01:47.150
close the monitoring gap; it is not permission to initiate

00:01:47.192 --> 00:01:51.025
therapy in a patient with acute deterioration without reassessment.

00:01:51.274 --> 00:01:54.538
Use the heart-failure label, not a remembered kidney schedule.

00:01:54.858 --> 00:01:58.186
Finerenone’s current US labeling includes adults with heart failure and

00:01:58.228 --> 00:02:01.187
left ventricular ejection fraction of at least 40 percent.

00:02:01.499 --> 00:02:04.593
Baseline potassium and E G F R are required.

00:02:04.913 --> 00:02:08.923
Do not initiate when potassium is above 5.0 milliequivalents per

00:02:08.966 --> 00:02:12.878
liter; initiation below E G F R 25 milliliters per

00:02:12.921 --> 00:02:15.353
minute per one point seven three square meters is not

00:02:15.396 --> 00:02:18.809
recommended. Strong C Y P 3 A 4 inhibitors and

00:02:18.852 --> 00:02:24.329
adrenal insufficiency are contraindications. Review interactions and the entire regimen.

00:02:24.628 --> 00:02:27.743
For the heart failure indication, starting and target doses depend

00:02:27.828 --> 00:02:31.028
on baseline E G F R, with subsequent decisions guided

00:02:31.156 --> 00:02:32.893
by potassium and kidney function.

00:02:33.222 --> 00:02:36.272
At Teresa’s stated baseline E G F R of 42,

00:02:36.507 --> 00:02:39.195
the label’s starting dose is 10 milligrams daily and target

00:02:39.280 --> 00:02:42.694
is 20 milligrams daily, subject to subsequent laboratory results and

00:02:42.736 --> 00:02:46.259
tolerability. Do not replace the heart failure dosing table with

00:02:46.301 --> 00:02:48.815
the chronic kidney disease-with-diabetes table.

00:02:49.153 --> 00:02:51.756
The heart failure label calls for potassium and E G

00:02:51.799 --> 00:02:55.041
F R four weeks after initiation and four weeks after

00:02:55.169 --> 00:03:00.132
dose adjustment, then periodically. Clinical changes may require earlier assessment.

00:03:00.401 --> 00:03:03.814
Use the current label for exact hold, restart and adjustment

00:03:03.857 --> 00:03:06.502
rules. The course does not replace those tables or a

00:03:06.545 --> 00:03:09.041
clinician’s judgment. Here is the decision.

00:03:09.318 --> 00:03:13.295
Teresa’s potassium is 4.7 and E G F R 42.

00:03:13.560 --> 00:03:17.485
After other eligibility and interaction checks, what completes a finerenone

00:03:17.613 --> 00:03:20.301
initiation plan? Pause here if you would like a moment

00:03:20.429 --> 00:03:22.681
to think it through. The best next step in this

00:03:22.767 --> 00:03:27.161
case is: Use the heart failure dosing instructions, arrange four-week

00:03:27.247 --> 00:03:31.300
potassium/E G F R testing, and name the reviewer and

00:03:31.343 --> 00:03:36.143
patient-contact process. The dose, tests, owner and communication process belong

00:03:36.313 --> 00:03:38.916
together. A laboratory order needs an owner.

00:03:39.087 --> 00:03:41.433
'Repeat labs' is not a complete plan.

00:03:41.732 --> 00:03:45.432
Specify the tests, date, location and responsible reviewer.

00:03:45.719 --> 00:03:48.365
The reviewer needs a process for acting on abnormal values

00:03:48.493 --> 00:03:51.223
and contacting Teresa. The team also needs a way to

00:03:51.266 --> 00:03:54.039
detect a test that was not completed; a missing result

00:03:54.210 --> 00:03:55.650
is not a normal result.

00:03:56.227 --> 00:03:59.427
For this case, the plan could read: 'Basic metabolic panel

00:03:59.513 --> 00:04:02.883
at four weeks after initiation, with potassium and E G

00:04:02.926 --> 00:04:06.638
F R review by the prescribing clinician; earlier clinical assessment

00:04:06.766 --> 00:04:09.085
if symptoms or intercurrent illness warrant.

00:04:09.272 --> 00:04:12.685
Nurse care coordinator checks completion and contacts the prescriber for

00:04:12.728 --> 00:04:16.610
missing or abnormal results. Results and instructions communicated to Teresa

00:04:16.824 --> 00:04:20.342
and documented.' The local team must assign real names and

00:04:20.385 --> 00:04:24.224
workable escalation thresholds. Confirm that the testing site is reachable

00:04:24.438 --> 00:04:25.953
and the order can be used there.

00:04:26.316 --> 00:04:28.875
Give Teresa a short written summary of when to go

00:04:29.046 --> 00:04:31.886
and whom to call. With her permission, include a support

00:04:32.100 --> 00:04:35.171
person. If a dose changes, the laboratory date must change

00:04:35.299 --> 00:04:37.902
with it; otherwise the chart can appear complete while the

00:04:37.945 --> 00:04:41.341
relevant monitoring is missed. Record that the result was reviewed

00:04:41.470 --> 00:04:44.541
and the patient informed. Sending a message into a portal

00:04:44.627 --> 00:04:47.311
that Teresa does not use may not complete the loop.

00:04:47.605 --> 00:04:50.165
Ask which contact method works for her and follow the

00:04:50.208 --> 00:04:52.832
organization’s privacy and communication policies.

00:04:53.066 --> 00:04:55.562
Explain benefit and risk in the same conversation.

00:04:55.797 --> 00:04:58.186
Teresa asks, 'Will this medicine keep me out of the

00:04:58.229 --> 00:05:02.599
hospital?' A useful answer respects both evidence and uncertainty: 'In

00:05:02.641 --> 00:05:05.756
a large trial, this treatment reduced the combined rate of

00:05:05.799 --> 00:05:08.544
worsening heart-failure events and cardiovascular death.

00:05:08.815 --> 00:05:11.290
It cannot promise that you will never need hospital care.

00:05:11.503 --> 00:05:14.703
We also need to watch potassium and kidney function.' Use

00:05:14.831 --> 00:05:17.705
the relevant population and endpoint when explaining a result.

00:05:18.062 --> 00:05:21.560
FINEARTS H F included mildly reduced and preserved ejection fraction;

00:05:21.774 --> 00:05:25.358
it counted recurrent worsening-heart failure events as well as cardiovascular

00:05:25.486 --> 00:05:28.505
death. A rate ratio for total events is not an

00:05:28.548 --> 00:05:30.959
individual patient’s chance of avoiding every event.

00:05:31.193 --> 00:05:34.607
The trial’s lack of a significant cardiovascular-death result alone should

00:05:34.649 --> 00:05:37.465
not be hidden. Ask Teresa to explain why the blood

00:05:37.508 --> 00:05:40.130
test matters. If she says it is only to see

00:05:40.173 --> 00:05:42.946
whether the drug is working, clarify the safety purpose.

00:05:43.202 --> 00:05:46.253
Hyperkalemia may not announce itself with a clear symptom.

00:05:46.530 --> 00:05:48.962
Monitoring is part of the treatment, even when she feels

00:05:49.048 --> 00:05:52.604
well. Do not let the routine pathway absorb an emergency.

00:05:53.030 --> 00:05:56.358
Now change the vignette. Teresa calls with new breathlessness at

00:05:56.401 --> 00:05:59.260
rest and chest pressure. This is a different decision from

00:05:59.302 --> 00:06:01.082
arranging the next routine blood test.

00:06:01.368 --> 00:06:05.890
Arrange emergency assessment; in the United States, severe or potentially

00:06:06.146 --> 00:06:09.090
life-threatening symptoms warrant calling 911.

00:06:09.474 --> 00:06:11.309
Do not ask her to wait for the scheduled visit

00:06:11.565 --> 00:06:13.985
or simply repeat an outpatient laboratory test.

00:06:14.272 --> 00:06:17.983
For nonemergency worsening symptoms, the care plan should explain how

00:06:18.026 --> 00:06:20.416
to reach the clinical team and when same-day advice is

00:06:20.501 --> 00:06:24.085
needed. Any individualized weight or symptom action plan should be

00:06:24.128 --> 00:06:25.523
provided by the treating team.

00:06:25.809 --> 00:06:29.052
Do not invent a universal diuretic self-adjustment rule from this

00:06:29.095 --> 00:06:32.508
case. Use teach-back while she is stable: 'If you develop

00:06:32.636 --> 00:06:35.111
chest pressure and cannot catch your breath at rest, what

00:06:35.153 --> 00:06:37.691
will you do?' Then ask whom she contacts for a

00:06:37.734 --> 00:06:41.062
nonemergency concern and when her next test and visit occur.

00:06:41.318 --> 00:06:44.006
Correct the plan in plain language rather than testing whether

00:06:44.091 --> 00:06:45.917
she can repeat clinical terminology.

00:06:46.249 --> 00:06:48.276
Turn a handoff into a completed action.

00:06:48.596 --> 00:06:51.753
A referral, order or discharge document is the start of

00:06:51.796 --> 00:06:55.917
a handoff. A completed handoff identifies the receiving clinician, the

00:06:55.960 --> 00:06:59.736
question to resolve, the current medicines and doses, recent results,

00:07:00.013 --> 00:07:02.072
pending tasks and the next contact.

00:07:02.467 --> 00:07:05.240
If no appointment is available, someone needs to address that

00:07:05.283 --> 00:07:08.478
gap rather than leaving an open-ended instruction to follow up.

00:07:08.730 --> 00:07:12.036
Evidence from STRONG H F supports the value of structured,

00:07:12.228 --> 00:07:15.428
closely monitored care after acute heart failure, but the trial

00:07:15.514 --> 00:07:18.511
was not restricted to heart failure with preserved ejection fraction.

00:07:18.820 --> 00:07:22.191
Its exact titration approach should not be transplanted wholesale to

00:07:22.233 --> 00:07:24.559
every woman with preserved ejection fraction.

00:07:25.007 --> 00:07:28.164
The transferable lesson here is to design follow-up that actively

00:07:28.292 --> 00:07:31.817
checks treatment and safety. For Teresa, the final note should

00:07:31.860 --> 00:07:34.889
make four things easy to find: what changed, what must

00:07:34.974 --> 00:07:37.406
be monitored, who will act and when she will hear

00:07:37.449 --> 00:07:40.333
from the team. At the next contact, confirm the test

00:07:40.418 --> 00:07:43.682
happened, the result was reviewed and the instruction reached her.

00:07:44.087 --> 00:07:46.263
The clinical outcome is not an order in the system;

00:07:46.519 --> 00:07:48.567
it is a patient who knows and can complete the

00:07:48.610 --> 00:07:50.680
next step. Here is the decision.

00:07:50.979 --> 00:07:52.600
The four-week result is missing.

00:07:52.984 --> 00:07:55.244
Which response best closes the care gap?

00:07:55.737 --> 00:07:57.571
Pause here if you would like a moment to think

00:07:57.614 --> 00:08:00.409
it through. The best next step in this case is:

00:08:00.686 --> 00:08:04.995
Check whether testing occurred, resolve access barriers, arrange needed testing

00:08:05.209 --> 00:08:08.278
and ensure clinician review. The team needs to track completion

00:08:08.406 --> 00:08:09.963
as well as interpret results.

00:08:10.369 --> 00:08:14.224
The takeaway: Monitoring and coordination are treatment tasks.

00:08:14.537 --> 00:08:17.694
Pair every medication change with a test date, a responsible

00:08:17.865 --> 00:08:21.573
reviewer, a communication plan and clear symptom escalation.

00:08:22.153 --> 00:08:24.671
Before we move on, let’s apply that reasoning in more

00:08:24.756 --> 00:08:27.572
detail. A safety call that cannot wait for the next

00:08:27.700 --> 00:08:31.543
blood test. Consider a separate development in Teresa’s story: after

00:08:31.671 --> 00:08:34.189
starting an S G L T 2 inhibitor she develops

00:08:34.317 --> 00:08:38.212
vomiting, poor intake, abdominal discomfort and breathlessness.

00:08:38.523 --> 00:08:41.937
Her home glucose is 146 milligrams per deciliter.

00:08:42.193 --> 00:08:45.393
This value does not rule out ketoacidosis associated with S

00:08:45.393 --> 00:08:46.708
G L T 2 treatment.

00:08:46.957 --> 00:08:50.370
Temporarily stop the medicine and arrange urgent clinical assessment for

00:08:50.413 --> 00:08:53.421
ketoacidosis, dehydration and other acute illness.

00:08:53.741 --> 00:08:56.557
Do not use a routine follow-up appointment or reassurance about

00:08:56.600 --> 00:08:58.319
the glucose value as the response.

00:08:58.758 --> 00:09:01.659
For a stable finerenone heart failure candidate with E G

00:09:01.659 --> 00:09:05.457
F R 42 and potassium 4.7, the current label begins

00:09:05.627 --> 00:09:09.382
at 10 milligrams daily, after the remaining eligibility and interaction

00:09:09.595 --> 00:09:12.941
checks. The heart failure target associated with that baseline renal

00:09:13.026 --> 00:09:17.164
category is 20 milligrams daily, if the follow-up potassium, kidney

00:09:17.207 --> 00:09:20.417
function and full dose-adjustment instructions support titration.

00:09:20.769 --> 00:09:22.988
A target is not an instruction to start at the

00:09:23.030 --> 00:09:26.081
target. For baseline E G F R at least 60,

00:09:26.316 --> 00:09:29.099
the heart failure starting and target doses differ again.

00:09:29.365 --> 00:09:33.675
Do not initiate finerenone with potassium above 5.0 milliequivalents per

00:09:33.718 --> 00:09:37.515
liter; initiation below E G F R 25 is not

00:09:37.600 --> 00:09:42.210
recommended. Check contraindications, including strong C Y P 3 A

00:09:42.210 --> 00:09:44.756
4 inhibitors and adrenal insufficiency.

00:09:45.183 --> 00:09:48.713
Use the heart failure-specific table when laboratory values change.

00:09:49.043 --> 00:09:53.267
A newly prescribed interacting medicine, dehydration, falling blood pressure or

00:09:53.352 --> 00:09:56.851
an acute illness can make a previously appropriate plan unsafe

00:09:57.107 --> 00:10:00.405
and may require assessment before the scheduled four-week review.

00:10:00.716 --> 00:10:03.020
Close the visit by asking Teresa to show how she

00:10:03.063 --> 00:10:06.135
will follow the plan: which medicine she is taking, when

00:10:06.263 --> 00:10:09.250
and where testing will occur, who will contact her, and

00:10:09.292 --> 00:10:11.071
which symptoms need immediate help.

00:10:11.356 --> 00:10:14.940
If a laboratory appointment or medication cannot be obtained, make

00:10:15.025 --> 00:10:17.116
the barrier visible to the responsible team.

00:10:17.415 --> 00:10:19.704
The plan is incomplete until it is feasible.

00:10:20.279 --> 00:10:22.711
Before you go, bring the three cases back to one

00:10:22.839 --> 00:10:25.549
question: what will you do differently at the next visit?

00:10:25.783 --> 00:10:29.175
Explain the symptom, use the endpoint the study actually measured,

00:10:29.325 --> 00:10:31.601
and give every monitoring plan an owner.

00:10:31.787 --> 00:10:35.200
You’ll find the source references, transcript and clinical resources beside

00:10:35.286 --> 00:10:38.272
this episode. To record your answers and complete the learning

00:10:38.401 --> 00:10:41.344
activity, return to the activity page for the questions and

00:10:41.387 --> 00:10:44.994
brief evaluation. This has been HEART RESERVE Clinical Conversations.

00:10:45.250 --> 00:10:47.551
I’m Lisa Zahakos. Thank you for listening.