Javed Butler

Heart failure related mortality is going… Up, up, up (since 2012) While GDMT implementation in clinical practices has been going almost nowhere Time to do something about this?

Evidence to routine clinical practice: 💔 BB ☠️⬇️ evidence since 1996, yet 27% of eligible patients not treated 🤬 MRA ☠️⬇️ evidence since 1999, yet 64% of eligible patients no Rx 🫣 SGLT2i ☠️⬇️ evidence since 2019, yet 66% of eligible patients no Rx Delay, delay, delay 🆘

Quadruple therapy use for HFrEF in routine clinical practice in the US EPIC COMOS 2023-2025: 18.2%* Pierce 2021-2022: 9% OPTUM 2021-2022: 2.3%* VA Health 2020-2023: 21.2%* *RASi component ARNI, ACEI, or ARB

Toxicity of Q-GDMT non-Rx for HFrEF Substantial financial toxicity from not prescribing Substantial health status toxicity from not prescribing Substantial quality of life toxicity from not prescribing Substantial survival toxicity from not prescribing Stop toxicity!

Very high per patient costs through 1 year post 🏨 for HF, irrespective of EF >40K $ SGLTi Rx ⬇️ costs by $2410-2688 1 year of dapagliflozin now costs $60 Besides ⬆️ patients’ ☠️ risk, not Rx SGLTi costs $2350-$2622 more in net cost than Rx SGLTi @SJGreene_md @JACCJournals

Got my CV prevention motivation at the airport.

@SubodhVermaMD’s @TEDx talk carries a message far beyond surgery: “Every human heart can break… every human heart can heal… and every human heart deserves care.” 🫀💙 A powerful reminder that dignity must come before difference. @DLBHATTMD @JavedButler1 @SVRaoMD @hmkyale

Important wisdom and messages for all of us. instagram.com/reel/DX16YOZOX…

🔥 off the press in @JACCJournals, we discuss the barriers & solutions to conduct CV trials in hemodialysis patients! Thankful @CVCTForum for uniting stakeholders. Thankful @FaiezZANNAD @JavedButler1 & coauthors. jacc.org/doi/10.1016/j.… @BCMHeart @BCM_CVRI @BCMDeptMedicine

⚠️ Are we missing heart failure events in clinical trials? @JavedButler1 @safchat @mvaduganathan @gcfmd @SJGreene_md 🔍 Traditional HF endpoints (hospitalization + IV diuretics) fail to capture patients managed in the outpatient setting 📊 Why this matters: • ~62% of incident HF diagnoses are made OUTSIDE acute care • 1-year mortality in outpatients without hospitalization: ~6.4% • First HF event is more often oral diuretic intensification (13% vs. 1% IV visit) • SGLT2i & ARNi reduce diuretic need → events become even harder to detect! ✅ Proposed solution: adopt a BROADER HF endpoint including: → Clinician-confirmed outpatient diagnoses → HF managed without hospitalization ⚖️ Pros: more sensitive, captures real-world burden ⚠️ Cons: lower specificity, risk of false positives → requires rigorous adjudication 📄 Butler J, et al. JACC. 2026;87(15):1907–1935. #Cardiology #HeartFailure #ClinicalTrials #Endpoints #SGLT2i #CardioTwitter

Cardiovascular Trials in Hemodialysis: Closing the Evidence Gap. doi.org/10.1016/j.jacc… Contributions from Baim faculty, @JavedButler1 and @gchertow. #BaimInstitute #ClinicalResearch #Cardiology #Nephrology

Heart Failure Prevention: Evidence Generation, Trial Design, and Regulatory Pathways. doi.org/10.1016/j.jacc… Contributions from Baim faculty, @JavedButler1 and @DrMarthaGulati. #BaimInstitute #ClinicalResearch #Cardiology #HeartFailure

In-Hospital Initiation of SGLT2 Inhibitors in Patients with Acute Heart Failure: A Meta-Analysis of RCTs with Trial Sequential Analysis - Journal of Cardiac Failure onlinejcf.com/article/S1071-… @MushoodCh @JCardFail @robmentz @SJGreene_md @DLBHATTMD @JavedButler1 @mvaduganathan

Designing Next-Generation Cardiometabolic Outcome Trials for Obesity Medicines. doi.org/10.1016/j.jacc… Contributions from Baim faculty, Dr. Darren McGuire and @JavedButler1. #BaimInstitute #ClinicalResearch #Cardiology

Biomarkers for Cardiovascular Drug Development: JACC State-of-the-Art Review. doi.org/10.1016/j.jacc… Contributions from Baim CSO, Dr. James Januzzi and @JavedButler1. #BaimInstitute #CinicalResearch #Cardiology

MASLD, MASH, and the CKM Spectrum: A Roadmap for Multiorgan Clinical Trial Design. doi.org/10.1016/j.jacc… Contributions from Baim CSO, Dr. James Januzzi and Baim faculty, @hvanspall, and @JavedButler1. #BaimInstitute #ClinicalResearch

Now in @JACCJournals, led by #HFC members @JavedButler1, @dranulala, @mvaduganathan, et al. Heart failure prevention in focus: this State-of-the-Art Review examines evidence gaps, trial design, and future priorities to advance HF prevention. jacc.org/doi/10.1016/j.…

Heart Failure Prevention: Evidence Generation, Trial Design, and Regulatory Pathways Despite advances in drugs and device-based therapies, once HF develops, these patients remain at an unacceptably high risk for mortality, morbidity, and adverse health status, underscoring the need for focus on primary prevention of HF. @JACCJournals @JavedButler1 @ShahzebKhanMD @NicolasGirerd @hfcollaboratory @HFA_President @mvaduganathan @dranulala @FaiezZANNAD @DrMarthaGulati jacc.org/doi/10.1016/j.…

Heart Failure Prevention: Evidence Generation, Trial Design, and Regulatory Pathways A fundamental reevaluation of preventive strategies for HF is required, moving incrementally from coronary disease–based approaches to more global populations, because many HF cases arise from nonatherosclerotic causes, such as obesity, hypertension, cancer therapies, and the cardio-kidney-metabolic syndrome. @JavedButler1 @mvaduganathan @ShahzebKhanMD @DrMarthaGulati @JACCJournals @ACCinTouch @safchat @hfcollaboratory @HFA_President jacc.org/doi/10.1016/j.…

The common approach of initiating 1 or 2 GDMT pillars after HFrEF diagnosis and deferring further adjustments until follow-up in 2 to 4 months is fundamentally incapable of delivering timely and comprehensive survival enhancing therapy This approach is also unfortunately lethal