The reality in community hospitals is even worse than you describe. There is a fifth reason GDMT is so accepted among cardiologists who absolutely know better.
I can list many examples of a newly diagnosed HFrEF patient being started on three to four of these drugs simultaneously while inpatient by a ‘cardiology Nurse Practioner’. This frees up the supervising attending to spend more time in the procedure room.
I even recall arguing with a cardiology NP that this 90 year old with newly diagnosed takuktsubos and MAPs hovering at 60 should not be simultaneously started on an ACE and a beta blocker.
Outpatient? NP run heart failure clinic where maximal GMDT and maximal diuresis is the name of the game. Rubber stamped by cardiologists.
Cardiology is one of the most competitive fields, yet somehow get 100 medical students or residents and ask them which IM speciality is the brainiest and you will never heard cardiology. Maybe EP if you’re lucky. Why is that? The heart is not any less complex or difficult, but the way we have decided to treat it with a cookbook is.
As an Oncologist I agree wth you. When reviewing guidelines such as NCCN, one has to be aware of the levels of evidence behind recommendations and then apply based on the patient in front of you who may not have necessarily met clinical trial inclusion. I have often found significant gaps in Up To Date in oncology such that I do not recommend it to trainees.
Couldn’t agree more. And you forgot one critically important point that is my main issue with GDMT - empagliflozin doesn’t change all cause mortality yet is wildly expensive. Its use is based on surrogate markers. I’m convinced that only people who haven’t actually read the EMPORER trials think its use is a good idea. And so the Cardiology teams are discharging patients from the hospital after a single abnormal echo, the hospital gives them 30 days of meds, and then the patient learns the cost of empagliflozin is $200-500 per month.
An 82 year old patient of mine who was previously on no medications called an ambulance because of chest pains. found to be having a STEMI. After be discharged from the hospital on GDMT he said "boy, the hospital sure can make a fella wish he'd died on his kitchen floor."
Good point. Everyone is different and reacts differently to each drug you give them. The possibility of accidental overdose increases as you increase the number of drugs in the real world.
I asked ChatGPT and she agrees with you! But seriously, great article. Standard of care, experts, mandates, sanctioned censoring...they all snuck into our daily vernacular while we were looking the other way and we accepted them whole hog...
I think the issue for you is more acute in the US, where it seems “guidelines” take on the air of commandments sent down from on high. Thankfully, here in Canada, that’s not been the case thus far, and I feel free to ignore guidelines that aren’t based closely to the evidence.
As you say, starting 4 drugs at once might be a good idea. All the proponents need to do, is to go out and prove it. But the eminence-based opinions masquerading as neutral science-based guidelines is annoying and nauseating.
I long for the days of yore, when guidelines could be relied upon as accurate compendiums of the state of the evidence, as opposed to the current era of guidelines leveraged as knowledge-translations tools targeting the lowest common denominator. Now get off my lawn!
I will echo the thoughts of many here. The GDMT discussion is just a microcosm of the larger issue: the general migration of patient care to something that was considered the worst possible insult when I began my career: cookbook medicine.
I begin each conversation with a patient by reminding them that they are their own science experiment and that our interaction will be spent squaring what I know about medicine/other patients/science with how that applies to them. My contribution is 20% knowing stuff and 80% figuring out how that will apply to them individually.
Government and other bureaucracies hate this approach. Just as with the lethal covid protocols, they love the one-size fits all mentality (yes, let us enshrine cookbook medicine) because then hard-to-control doctors looking out for their patients just become cogs to follow the rules. So we are now inundated with things like GDMT that are unsupportable but often quasi-enforced.
The sad thing is that many of the MDs graduating now (and I teach in a medical school) just love cookbook medicine. They are always hoping to get a list to follow so they can follow it blindly. That is why things like GDMT (or a long list of others) manage to prevail. Some of this is traceable to the diminution of merit as a selection tool/measurement tool for medical school. Some just to the overwhelming shift to doctors-as-employees rather than as patient advocates. But none of it good for either doctors or patients.
Medicine is the ultimate n-of-1 profession. As that continues to erode, patient care erodes with it and so does the necessity of having physicians at all (which will make many bureaucrats very happy). I spend most of my time trying to fight this trend, but the going is slow. One hopes that the remaining practitioners that understand the individuality of patients will rise up and buck this trend.
Bottom line is....one size fits all medical is expedient, but not always appropriate.
In Vet med, we see this a lot as well.
Formulaic medicine is good and bad. It's easy....so that's good, but it goes against critical thinking.
It assumes all patients with a certain condition will respond the same....and anyone in practice for any amount of time will know this is a fallacy.
Of course, because of the lack of personal interaction with doctors and patients, who didn't see this coming?
It tracks along with 'EVERYONE needs a vaccine, regardless of risk factors...because.........' Still waiting for the justification for toddlers getting COVID vaxx to make any sense.
AND....God forBID you ask a specialist a question.....then the real fun starts.
Good essay. Imagine if prescribers treated hypertension by the same rationale? Just pile on the ACE-I, ARB, CCB, BB, diuretic, etc. for your patients. It's not hard to see that this could be extremely harmful, even deadly when the patient has a stroke or falls down the stairs from orthostasis.
What’s lacking here is a near real time aggregation of data into a clinical registry that can be applied to developing, evaluating, and updating published best practices
Valid and well stated points! It’s not GDMT per se that is problematic, but the dogmatic use of it at expense of individualized care. One obvious example I’ve seen is unnecessary delays in referral for cardiac resynchronization in patients with LBBB so that effect of SGLT2-i could be evaluated first.
Apr 20, 2023·edited Apr 20, 2023Liked by Adam Cifu, MD
Standard of care? In the medical community? Exactly what is that standard that the medical mafia adhered to over the last 3 years? However, this is a tremendous article and really gets to the "heart" of the matter.
..."We do not know that starting all of them, often at once, improves quality of life or mortality"...you could be talking about the entire vaccination schedule as well.
Again, I have not taken vaccines in over 50 years and am currently treating my heart problems myself with herbs and other things. I am not on any drugs at age 73, but probably could be put on a half dozen drugs if I let the docs have their way. Would my life be improved? Would I live longer? Would my problems be cured? Based on the above article, I would say NO.
Hi. Australian HF cardiologist here. I can only agree partially with your position. GDMT is clearly being oversold and the 1 size fits all is not the right approach. I agree - trial from SOLVD to EMPEROR are a narrow subset of patients we see in the real world. Clearly uptitrating all drugs rapidly in elderly comorbid patients may lead to significant side effects abd the goal should be quality of life/functional capacity- some art of medicine is needed. Guidelines are just guidelines- not rules. PARADIGM had a run in phase for drug tolerance just like original valsartsn studies- so no surprise some patients won’t tolerate our combo of dtugs. Having said that STOP-HF in a very select group clearly shows that some patients do better with maximising therapy -GDMT within 2 weeks. We need to choose wisely. My concern with GDMT is the 4 pillars. This implies all therapies are equal- they are not. Beta blockers have highest efficacy followed by spironolactone yet in advanced economies we fail to adequately use cheap spironolactone. In the meantime SGLT -2 are being promoted aggressively l. This is especially now the HFpEF trials are “positive”- only reducing HF hospitalisation but not all cause hospitalisation. Big pharma wants us to believe SGLT2 should be given to anyone with HF regardless of EF or aetiology. That’s the marketing message and it is a con...
I'd just add that STRONG-HF wasn't a fair comparison, was like comparison 0 to 1 (or 0% to 100% GMDT) with no space inbetween. We got to know with the trial that 1 was better than 0 but still don't know if 0.5-0.75 will be better than 1.
As a IM resident I really like Adam's pieces and love the whole them of one size doesn't fits all, but I think here there were some mix between just "initiating the medicine in a short-term period with careful side effects monitoring" with "initiating the whole 4 pillars in their maximum strength like some aggressive chess player" Agree with first, don't agree with second, and from what I know guidelines don't clearly support the second.
If you ask me about the whole concept of uptitrating the max we can: there's where I generically disagree with guidelines. It doesn't goe along with the minimum possible dosis concept of the majority of the pharmacological world (read, listen and see James McCormack work for that) and, as far as I know, no trial looking specifically for that.
Anyway, I'm just a tiny grain of the vast land of the medical world.
Excellent points. I use the same approach to treating heart failure as yourself, and the SGLT2 use is being pushed hard in Canada as well. Pushing all 4 drugs at the same time makes it very hard to sort out which dug is responsible for side effects, a significant issue in the elderly and those with multiple comorbidities. Thanks for your comments.
The reality in community hospitals is even worse than you describe. There is a fifth reason GDMT is so accepted among cardiologists who absolutely know better.
I can list many examples of a newly diagnosed HFrEF patient being started on three to four of these drugs simultaneously while inpatient by a ‘cardiology Nurse Practioner’. This frees up the supervising attending to spend more time in the procedure room.
I even recall arguing with a cardiology NP that this 90 year old with newly diagnosed takuktsubos and MAPs hovering at 60 should not be simultaneously started on an ACE and a beta blocker.
Outpatient? NP run heart failure clinic where maximal GMDT and maximal diuresis is the name of the game. Rubber stamped by cardiologists.
Cardiology is one of the most competitive fields, yet somehow get 100 medical students or residents and ask them which IM speciality is the brainiest and you will never heard cardiology. Maybe EP if you’re lucky. Why is that? The heart is not any less complex or difficult, but the way we have decided to treat it with a cookbook is.
Thank you. I always learn something new from your posts.
As an Oncologist I agree wth you. When reviewing guidelines such as NCCN, one has to be aware of the levels of evidence behind recommendations and then apply based on the patient in front of you who may not have necessarily met clinical trial inclusion. I have often found significant gaps in Up To Date in oncology such that I do not recommend it to trainees.
Couldn’t agree more. And you forgot one critically important point that is my main issue with GDMT - empagliflozin doesn’t change all cause mortality yet is wildly expensive. Its use is based on surrogate markers. I’m convinced that only people who haven’t actually read the EMPORER trials think its use is a good idea. And so the Cardiology teams are discharging patients from the hospital after a single abnormal echo, the hospital gives them 30 days of meds, and then the patient learns the cost of empagliflozin is $200-500 per month.
An 82 year old patient of mine who was previously on no medications called an ambulance because of chest pains. found to be having a STEMI. After be discharged from the hospital on GDMT he said "boy, the hospital sure can make a fella wish he'd died on his kitchen floor."
Good point. Everyone is different and reacts differently to each drug you give them. The possibility of accidental overdose increases as you increase the number of drugs in the real world.
I asked ChatGPT and she agrees with you! But seriously, great article. Standard of care, experts, mandates, sanctioned censoring...they all snuck into our daily vernacular while we were looking the other way and we accepted them whole hog...
Fine tuning any condition is an out pt ambulatory process.
Great post.
I think the issue for you is more acute in the US, where it seems “guidelines” take on the air of commandments sent down from on high. Thankfully, here in Canada, that’s not been the case thus far, and I feel free to ignore guidelines that aren’t based closely to the evidence.
As you say, starting 4 drugs at once might be a good idea. All the proponents need to do, is to go out and prove it. But the eminence-based opinions masquerading as neutral science-based guidelines is annoying and nauseating.
I long for the days of yore, when guidelines could be relied upon as accurate compendiums of the state of the evidence, as opposed to the current era of guidelines leveraged as knowledge-translations tools targeting the lowest common denominator. Now get off my lawn!
I will echo the thoughts of many here. The GDMT discussion is just a microcosm of the larger issue: the general migration of patient care to something that was considered the worst possible insult when I began my career: cookbook medicine.
I begin each conversation with a patient by reminding them that they are their own science experiment and that our interaction will be spent squaring what I know about medicine/other patients/science with how that applies to them. My contribution is 20% knowing stuff and 80% figuring out how that will apply to them individually.
Government and other bureaucracies hate this approach. Just as with the lethal covid protocols, they love the one-size fits all mentality (yes, let us enshrine cookbook medicine) because then hard-to-control doctors looking out for their patients just become cogs to follow the rules. So we are now inundated with things like GDMT that are unsupportable but often quasi-enforced.
The sad thing is that many of the MDs graduating now (and I teach in a medical school) just love cookbook medicine. They are always hoping to get a list to follow so they can follow it blindly. That is why things like GDMT (or a long list of others) manage to prevail. Some of this is traceable to the diminution of merit as a selection tool/measurement tool for medical school. Some just to the overwhelming shift to doctors-as-employees rather than as patient advocates. But none of it good for either doctors or patients.
Medicine is the ultimate n-of-1 profession. As that continues to erode, patient care erodes with it and so does the necessity of having physicians at all (which will make many bureaucrats very happy). I spend most of my time trying to fight this trend, but the going is slow. One hopes that the remaining practitioners that understand the individuality of patients will rise up and buck this trend.
Bottom line is....one size fits all medical is expedient, but not always appropriate.
In Vet med, we see this a lot as well.
Formulaic medicine is good and bad. It's easy....so that's good, but it goes against critical thinking.
It assumes all patients with a certain condition will respond the same....and anyone in practice for any amount of time will know this is a fallacy.
Of course, because of the lack of personal interaction with doctors and patients, who didn't see this coming?
It tracks along with 'EVERYONE needs a vaccine, regardless of risk factors...because.........' Still waiting for the justification for toddlers getting COVID vaxx to make any sense.
AND....God forBID you ask a specialist a question.....then the real fun starts.
Good essay. Imagine if prescribers treated hypertension by the same rationale? Just pile on the ACE-I, ARB, CCB, BB, diuretic, etc. for your patients. It's not hard to see that this could be extremely harmful, even deadly when the patient has a stroke or falls down the stairs from orthostasis.
What’s lacking here is a near real time aggregation of data into a clinical registry that can be applied to developing, evaluating, and updating published best practices
Valid and well stated points! It’s not GDMT per se that is problematic, but the dogmatic use of it at expense of individualized care. One obvious example I’ve seen is unnecessary delays in referral for cardiac resynchronization in patients with LBBB so that effect of SGLT2-i could be evaluated first.
Standard of care? In the medical community? Exactly what is that standard that the medical mafia adhered to over the last 3 years? However, this is a tremendous article and really gets to the "heart" of the matter.
..."We do not know that starting all of them, often at once, improves quality of life or mortality"...you could be talking about the entire vaccination schedule as well.
Again, I have not taken vaccines in over 50 years and am currently treating my heart problems myself with herbs and other things. I am not on any drugs at age 73, but probably could be put on a half dozen drugs if I let the docs have their way. Would my life be improved? Would I live longer? Would my problems be cured? Based on the above article, I would say NO.
Excellent article!!! I agree 100%. I'm currently engaged in this struggle myself. You scooped me on this ;)
Our loss! Feel free to strengthen my argument.
Hi. Australian HF cardiologist here. I can only agree partially with your position. GDMT is clearly being oversold and the 1 size fits all is not the right approach. I agree - trial from SOLVD to EMPEROR are a narrow subset of patients we see in the real world. Clearly uptitrating all drugs rapidly in elderly comorbid patients may lead to significant side effects abd the goal should be quality of life/functional capacity- some art of medicine is needed. Guidelines are just guidelines- not rules. PARADIGM had a run in phase for drug tolerance just like original valsartsn studies- so no surprise some patients won’t tolerate our combo of dtugs. Having said that STOP-HF in a very select group clearly shows that some patients do better with maximising therapy -GDMT within 2 weeks. We need to choose wisely. My concern with GDMT is the 4 pillars. This implies all therapies are equal- they are not. Beta blockers have highest efficacy followed by spironolactone yet in advanced economies we fail to adequately use cheap spironolactone. In the meantime SGLT -2 are being promoted aggressively l. This is especially now the HFpEF trials are “positive”- only reducing HF hospitalisation but not all cause hospitalisation. Big pharma wants us to believe SGLT2 should be given to anyone with HF regardless of EF or aetiology. That’s the marketing message and it is a con...
Agreed.
I'd just add that STRONG-HF wasn't a fair comparison, was like comparison 0 to 1 (or 0% to 100% GMDT) with no space inbetween. We got to know with the trial that 1 was better than 0 but still don't know if 0.5-0.75 will be better than 1.
As a IM resident I really like Adam's pieces and love the whole them of one size doesn't fits all, but I think here there were some mix between just "initiating the medicine in a short-term period with careful side effects monitoring" with "initiating the whole 4 pillars in their maximum strength like some aggressive chess player" Agree with first, don't agree with second, and from what I know guidelines don't clearly support the second.
If you ask me about the whole concept of uptitrating the max we can: there's where I generically disagree with guidelines. It doesn't goe along with the minimum possible dosis concept of the majority of the pharmacological world (read, listen and see James McCormack work for that) and, as far as I know, no trial looking specifically for that.
Anyway, I'm just a tiny grain of the vast land of the medical world.
Peace.
Excellent points. I use the same approach to treating heart failure as yourself, and the SGLT2 use is being pushed hard in Canada as well. Pushing all 4 drugs at the same time makes it very hard to sort out which dug is responsible for side effects, a significant issue in the elderly and those with multiple comorbidities. Thanks for your comments.