Weight-loss program in HF clinic setting may benefit patients with obesity, HF
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Key takeaways:
- It is feasible to establish a weight-loss program in a community heart failure clinic.
- The weight loss in patients who took semaglutide or tirzepatide was similar to that observed in clinical trials.
A cardiology-driven clinic for outpatients with heart failure appears to be an effective setting for weight loss in patients with obesity and HF, according to a research letter published in JACC: Advances.
“There’s a substantive category of patients with heart failure with preserved ejection fraction who have the obesity phenotype. It’s an important risk enhancer and an important comorbidity,” Ankur Kalra, MD, FACP, FACC, FSCAI, interventional cardiologist at Franciscan Health in Lafayette, Indiana, primary investigator at Krannert Cardiovascular Research Center and adjunct clinical associate professor of medicine at Indiana University School of Medicine, told Healio. “The belief is that if these patients lose weight, they may get cured of that phenotype. There are not many therapies other than SGLT2 inhibitors that have shown any benefit in terms of morbidity and mortality in this population. We thought [weight loss] was an important adjunct in addition to what is available for patients with HFpEF.”
Kalra, Vijay U. Rao, MD, PhD, director of heart failure and cardio-oncology and co-director of the anticoagulation program at Franciscan St. Francis Health, and colleagues, including cardiologists, endocrinologists, bariatric surgeons, primary care providers, nurses, health coaches and lifestyle program administrators, developed an HF obesity algorithm and implemented it in the setting of a HF clinic. They identified potential participants among those who had HF (most of whom had HFpEF), had obesity and were willing to participate in lifestyle modifications.
Multifaceted program
The program included the following components:
- Healthy Living Center, consisting of one-on-one coaching from an advanced practice registered nurse and a personalized plan for weight-loss counseling; lifestyle modifications; and use of intensive-behavioral therapy for weight-loss management;
- Journey to Health, consisting of a yearlong program of combination visits with PCPs and certified health coaches; a nutrition and weight-loss program; tracking of body composition; incorporation of a diabetes prevention program if applicable; group cooking classes; and group fitness classes;
- if necessary, a cardiac rehabilitation program, consisting of an individualized exercise plan (aerobic, strength training, flexibility) and outpatient education by dietitians, exercise physiologists, pharmacists and diabetes educators;
- Silver Sneakers, a fitness and wellness program designed for adults aged 65 years and older on certain Medicare programs, consisting of in-person and virtual options with gym access to participating locations, cardio equipment, pool activities, tennis and walking tracks with online resources on nutrition and fitness; and
- a shared decision-making process, including discussion of cost and consideration of diabetes status, regarding potential use of GLP-1 or GIP/GLP-1 receptor agonists, usually semaglutide (Ozempic or Wegovy, Novo Nordisk) or tirzepatide (Mounjaro or Zepbound, Eli Lilly).
“A key component is making effective nutrition choices and having the access to do so,” Kalra told Healio. “You can’t change the ZIP codes people live in, which has been shown to have an effect on the choices made for nutrition, but providing them the education about what is required in addition to prescribing them medication, and making sure these patients have access to advanced practice providers in case they need fine-tuning of their diuretic regimen or require access to the health care system [requires] a support structure that is thought out very meticulously.”
The program screened 58 patients, of whom 21 started a GLP-1 or GIP/GLP-1 receptor agonist plus lifestyle modifications, five started lifestyle modifications alone and 32 were lost to follow-up due to drug-related costs and/or not wanting to do lifestyle modifications.
“The biggest challenge is the financial toxicity,” Kalra told Healio. “Also, a lot of patients had diabetes as a comorbidity and were or had been on insulin, and this would be another injectable for them. It also has to do with how people perceive themselves. At the time of diagnosis of heart failure with preserved ejection fraction, I think some were not convinced they had ‘heart failure’ because they felt ‘fine’ otherwise. If that is the case and you are started on agents, some of which are expensive, then unfortunately it has to do with trust in the medical community, which I think has been eroded in the post-pandemic world that we live in. It was a challenge to convince some of these patients that they truly had the diagnosis that they had.”
Of the 21 patients who started a GLP-1 or GIP/GLP-1 receptor agonist plus lifestyle modifications, the median age was 57 years, 62% were women, 80.9% had HFpEF, 47.6% had preexisting diabetes, none were on other weight-loss medications, the median starting weight was 295 lb and the median starting BMI was 43.65 kg/m2.
After a median follow-up of 182 days, the patients who started a GLP-1 or GIP/GLP-1 receptor agonist plus lifestyle modifications had a median weight loss of 21 lb, or –9.4% of body weight, figures similar to those seen in randomized trials of GLP-1 or GIP/GLP-1 receptor agonists, Kalra, Rao and colleagues wrote.
‘A cardiology drug now’
“[Cardiologists] do have to take the onus on ourselves to become familiar with this drug class and to be comfortable in prescribing these drugs,” Kalra told Healio. “We certainly need to start talking to our support staff in clinics to arrange for seamless mechanisms for prior authorization approvals. The SELECT trial showed that regardless of diabetes status, for patients with cardiovascular disorders who had a high BMI, there is now a mortality benefit to these drugs. [Semaglutide] is a cardiology drug now, as far as I am concerned.”
Kalra told Healio that researchers from a range of specialties are working on incorporating the program into a variety of clinics across the Franciscan Health system, and a manuscript of results from multiple sites is in progress.
“We want to demonstrate that these programs are important to be structured and disseminated in the communities, because that’s where these patients are,” he said. “They are not only in academic health centers or in the realms of clinical trials.”
For more information:
Ankur Kalra, MD, FACP, FACC, FSCAI, can be reached at akalra@alumni.harvard.edu.
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