General physicians' perspectives on SGLT2 inhibitors for heart failure.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are novel agents for heart failure (HF) and are now recommended in guidelines. Understanding general physicians' perspectives can help to optimise utilisation of this new medication. AIM: To understand the clinical concerns and barriers from general physicians about prescribing SGLT2is in a general medicine cohort. METHODS: A questionnaire exploring clinicians' experience, comfort level and barriers to prescribing SGLT2is in patients with HF, incorporating two clinical scenarios, was disseminated to Internal Medicine Society of Australia and New Zealand members over a 2-month period. RESULTS: Ninety-eight participants responded to the questionnaire (10.8% response rate). Most respondents (66.3%) were senior medical staff. Most participants worked in metropolitan settings (64.3%) and in public hospital settings (83.7%). For HF with reduced ejection fraction, 23.5% of participants reported prescribing SGLT2is frequently (defined as prescribing SGLT2is frequently over 75% of occasions). For HF with preserved ejection fraction, 57.1% of participants reported prescribing SGLT2is less than 25% of the time. Almost half of the participants (44%) expressed a high level of familiarity with therapeutic knowledge of SGLT2is, while 47% indicated high familiarity with potential side effects. Patient complexity, cost of medications and discontinuity of care were identified as important barriers. Euglycemic diabetic ketoacidosis was the side effect that caused the most hesitancy to prescribe SGLT2is in 48% of the respondents. CONCLUSION: General physicians in Australia and Aotearoa New Zealand are familiar with the therapeutic knowledge and side effects of SGLT2is. Patient complexity, medication cost and discontinuity of care were significant barriers to the use of SGLT2is for HF among general physicians.

Physician Perceptions of Medication Prescribing in Heart Failure: A Scoping Review.

INTRODUCTION: The swift uptake of new medications into clinical practice has many benefits; however, slow uptake has been seen previously with other guideline-directed medical therapies (GDMT) in heart failure (HF). Sodium glucose co-transporter 2 inhibitors are a novel therapy in HF proven to be efficacious and will have beneficial clinical outcomes if prescribed. Understanding physician perspectives on prescribing GDMT in HF can help target strategies to bridge the gap between guidelines and practice. METHODS: The study followed the PRISMA guide for scoping reviews. A search was conducted using EMBASE, Medline, and PubMed databases in April 2024. Studies included were those using qualitative methods to assess physician perspectives towards prescribing any HF medication. Common themes were identified through thematic synthesis following the methods from Cochrane Training and using software MAXQDA Analysis Pro. RESULTS: 708 studies were found in the search, with 23 full studies included. The most pertinent barriers identified were concern for medication adverse effects, unclear role responsibilities between physicians of different specialities, patient co-morbidities, and unwillingness to alter therapies of stable patients. The most identified enablers included awareness of efficacy, influence from colleagues, and the use of multi-media approaches for information dissemination. Perceptions were also found to change over time and vary among prescriber groups. CONCLUSIONS: Physicians perceive common barriers and enablers of prescribing GDMT in HF, despite differences in prescriber groups and time periods. The identified barriers and enablers may be targeted to improve implementation of GDMT into clinical practice.

Pre-eclampsia and long-term cardiac dysfunction: A review of asymptomatic cardiac changes existing well beyond the post-partum period.

BACKGROUND: Pre-eclampsia is a disease of pregnancy characterised by the manifestations of multi-organ dysfunction. The recent use of transthoracic echocardiography in the assessment of women with pre-eclampsia has allowed the detection of cardiac systolic and diastolic dysfunction in the acute phase. Women with a history of pre-eclampsia also have increased lifelong risks of cardiovascular disease and mortality that persists well beyond the post-partum period. These developments raise the possibility that pre-eclampsia may be an early marker of cardiovascular disease and the potential role for echocardiography in guiding the detection and management of this. This review aims to summarise the existing evidence of echocardiographic cardiac assessment of women with a history of pre-eclampsia performed more than 12 weeks post-partum. METHODS: A systematic search of PubMed and OVID EMBASE databases was performed to identify studies featuring assessment of cardiac function performed after 12 weeks post-partum in women with a history of pre-eclampsia. Studies without post-partum cardiac assessment or with other documented causes for cardiomyopathy were excluded. RESULTS: Thirteen studies were identified that measured cardiac function by transthoracic echocardiography between 6 months and 18 years following a pregnancy complicated by pre-eclampsia. Common findings across the studies were of increased diastolic dysfunction, increased left ventricular mass index (LVMI) and concentric hypertrophy in women with a history of pre-eclampsia, as compared to women with uncomplicated pregnancy histories. This was predominantly seen in those with a history of early or preterm pre-eclampsia. CONCLUSIONS: Women with a history of early or preterm pre-eclampsia have an increased prevalence of diastolic dysfunction. This review demonstrates that the cardiac dysfunction associated with previous pre-eclampsia is quantifiable and persistent. Progression of heart failure from asymptomatic to symptomatic stages carries a fivefold increase in mortality. The use of echocardiography could detect cardiac dysfunction in the asymptomatic stage and guide more intensive risk factor modification in these women.