Do We Need A Wider Therapeutic Paradigm For Heart Failure With Comorbidities?: A Remote Australian Perspective

Abstract

Forty percent of CHF clients can suffer with up to five or more comorbidity, a rate that is likely higher in the NT. Large CHF trials AbstractCongestive Heart Failure a leading cause of morbidity and mortality is often associated with comorbidities and with it polypharmacy. Improved pathophysiological understanding, the available therapeutics, clinical guidelines and structured programs for comprehensive care have not benefited all clients in the Northern Territory of Australia. The Northern Territory has both a unique geography and demography including a sizeable Indigenous population. Additional factors that can affect heart failure management are prevalent in remote areas and are not well addressed within randomized controlled trials. This review is focused on building a case for widening the therapeutic paradigm for heart failure with comorbidities. We focus on a brief overview of heart failure and its associated comorbidities, the common overlapping physiological processes, the interpretation of the external validity of trial evidence, and finally exploring the available evidence for the important therapies within the guidelines. A need to consider a wider therapeutic paradigm may also have relevance for clients in other health systems.

Northern Territory Perspectives on Heart Failure with Comorbidities – Understanding Trial Validity and Exploring Collaborative Opportunities to Broaden the Evidence Base

“…An important area often overlooked is the pill burden, its effects on clients psyche and eventually adherance [24][25][26][27]. Box 2 explores several clinical scenarios not uncommon to the NT.…”

Why it Remains Difficult for Remote Cardiologist to Obtain the Locus of Control for Ambulatory Health Care Conditions Such as Congestive Heart Failure? A Tug of War between General Practice, Administrators and Implementable Research Findings

“…This first hurdle usually does not greatly affect strategies that call for increased resources in staffing and infrastructure. As we have previously highlighted this one-dimensional strategy may not however in the long term achieve the programme goals (1,2 Jou rn a l o f Ge ner a l P r a c tic e for community based interventions. An example we highlight here has been in shaping a CDSMP, as part of a CHF disease management programme.…”

“…These issues becomes more difficult when findings involve implementing a new strategy or if there are more than one choice available. We have previously discussed some of these challenges and potential solutions for the NT [1][2][3][4][5]. In this short commentary, we discuss briefly some issues on the implementation strategies for CHF best practice in the Northern Territory (NT) of Australia and why it remains difficult for the cardiologists who are held to account to also maintain a degree of control on the process.…”

“…• Principles on interpreting external validity of studies [3] • Importance of physiological modulation behind the drug therapies, thus broadening the acceptability for physiological based prescribing principles for future studies in CHF, particularly with comorbidities [2,3] • The axis of control for subspecialty ambulatory health care conditions that require collaborative and multifaceted approaches to research practice [1] It would appear to improve CHF care; there is a need for a broader range of interventional research tools that focus on implementation in a heterogeneous group and allow a broader range of questions to be answered, that can similarly steer policy. We would encourage clinicians in similar clinical settings to contribute further in this area.…”

Bedside–to-Bench Translational Research for Chronic Heart Failure: Creating an Agenda for Clients who do Not Meet Trial Enrollment Criteria

“…Medication side effects, extra class interactions, and pill burden are poorly factored in RCT or guidelines. 5 , 6 Posttranslational research for evidence to simplify therapeutic regimes or to improve efficacy is also lacking. 5 , 6 …”