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Updated: Oct 7, 2025
Lumped-Parameter and Finite Element Modeling of Heart Failure with Preserved Ejection Fraction
Published on: February 13, 2021
Heart Failure Spending Function: An Investment Framework for Sequencing and Intensification of Guideline-Directed
Larry A Allen1, John R Teerlink2, Stephen S Gottlieb3
1Division of Cardiology, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora (L.A.A.).
Insights
We propose a heart failure spending function to guide tailored intensification of guideline-directed medical therapies (GDMT). This framework maximizes benefits by considering patient reserves and minimizing harm from overspending, optimizing heart failure management.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Heart failure with reduced ejection fraction (HFErEF) management involves numerous guideline-directed medical therapies (GDMT).
- The benefits of GDMT are often additive, but so are the burdens on patients.
- Optimizing GDMT requires balancing therapeutic gains against potential adverse events and patient burden.
Purpose of the Study:
- To introduce a conceptual framework, the heart failure spending function, for personalized GDMT intensification in HFErEF.
- To guide clinicians in sequencing and intensifying therapies to maximize cardiac benefits while minimizing harm.
- To provide a model for evaluating the relative value of existing and novel HFErEF therapies.
Main Methods:
- Conceptual framework development based on patient physiological and psychosocial reserves.
- Identification of key domains: blood pressure, heart rate, serum creatinine, potassium, and out-of-pocket costs.
- Prioritization of GDMT initiation and intensification based on expected cardiac benefit and patient reserve capacity.
Main Results:
- The spending function conceptualizes patient reserve as a resource to be "spent" for therapeutic gain.
- Underspending reserve limits GDMT benefits, while overspending leads to patient harm.
- Balancing multiple agents across varied physiological domains against cost and complexity is crucial.
Conclusions:
- The heart failure spending function offers a novel approach to tailored GDMT intensification in HFErEF.
- This framework aims to optimize therapeutic opportunities and limit adverse events and patient burden.
- Further research is needed to validate and refine the clinical application of the spending function in routine care.
Abstract:
Heart failure with reduced ejection fraction is managed with increasing numbers of guideline-directed medical therapies (GDMT). Benefits tend to be additive. Burdens can also be additive. We propose a heart failure spending function as a conceptual framework for tailored intensification of GDMT that maximizes therapeutic opportunity while limiting adverse events and patient burden. Each patient is conceptualized to have reserve in physiological and psychosocial domains, which can be spent for a future return on investment. Key domains are blood pressure, heart rate, serum creatinine, potassium, and out-of-pocket costs. For each patient, GDMT should be initiated and intensified in a sequence that prioritizes medications with the greatest expected cardiac benefit while drawing on areas where the patient has ample reserves. When reserve is underspent, patients fail to gain the full benefit of GDMT. Conversely, when a reserve is fully spent, addition of new drugs or higher doses that draw upon a domain will lead to patient harm. The benefit of multiple agents drawing upon varied physiological domains should be balanced against cost and complexity. Thresholds for overspending are explored, as are mechanisms for implementing these concepts into routine care, but further health care delivery research is needed to validate and refine clinical use of the spending function. The heart failure spending function also suggests how newer therapies may be considered in terms of relative value, prioritizing agents that draw on different spending domains from existing GDMT.
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