From the Guidelines
For an African American patient with systolic heart failure and reduced ejection fraction, treatment should be initiated with a combination of medications including an ACE inhibitor or an angiotensin II receptor blocker (ARB), a beta-blocker, and an aldosterone antagonist, as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 1.
Initial Treatment
Specifically, consider starting with:
- Lisinopril (ACE inhibitor) 5-10 mg orally once daily, titrating up to 20-40 mg daily as tolerated
- Metoprolol succinate (beta-blocker) 25-50 mg orally once daily, titrating up to 100-200 mg daily as tolerated
- Spironolactone (aldosterone antagonist) 12.5-25 mg orally once daily, titrating up to 25-50 mg daily as tolerated
Additional Considerations
Additionally, consider the use of an SGLT2 inhibitor such as sacubitril/valsartan, which has shown benefits in patients with heart failure with reduced ejection fraction (HFrEF), as an alternative to ACE inhibitors or ARBs if not tolerated, as suggested by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
Add-on Therapy
Hydralazine and isosorbide dinitrate can also be considered as add-on therapy for African American patients with persistent symptoms despite optimal treatment with ACE inhibitors or ARBs and beta-blockers, as recommended by the 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults 1.
Monitoring and Lifestyle Modifications
It is crucial to monitor the patient's renal function, potassium levels, and blood pressure closely while initiating and titrating these medications, as emphasized by the 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment 1. Lifestyle modifications including a low-sodium diet, regular exercise, and weight management should also be emphasized.
Follow-up
Regular follow-up appointments are necessary to assess the patient's response to treatment and adjust the medication regimen as needed to achieve optimal symptom control and slow disease progression, as outlined in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
From the FDA Drug Label
The Randomized Spironolactone Evaluation Study was a placebo controlled, double-blind study of the effect of spironolactone on mortality in patients with highly symptomatic heart failure and reduced ejection fraction To be eligible to participate patients had to have an ejection fraction of ≤ 35%, NYHA class III-IV symptoms, and a history of NYHA class IV symptoms within the last 6 months before enrollment. There were too few non-whites in Randomized Spironolactone Evaluation Study to evaluate if the effects differ by race.
The treatment for an African American patient with systolic heart failure and reduced ejection fraction is not directly addressed in the provided drug labels.
- Key points:
- The study had too few non-white patients to evaluate the effects of spironolactone by race.
- Sacubitril and valsartan tablets are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction, but the label does not provide specific information for African American patients.
- Clinical decision: The FDA drug label does not provide sufficient information to guide treatment for an African American patient with systolic heart failure and reduced ejection fraction. 2 3
From the Research
Treatment for African American Patients with Systolic Heart Failure and Reduced Ejection Fraction
The treatment for African American patients with systolic heart failure and reduced ejection fraction involves a combination of medications, including:
- Isosorbide dinitrate and hydralazine, which have been shown to reduce mortality and morbidity in African American patients with heart failure and reduced ejection fraction 4, 5, 6
- Angiotensin-converting enzyme (ACE) inhibitors and beta blockers, which are standard evidence-based medical therapies for heart failure, although their efficacy in African Americans has been debated 5
- Other medications such as digoxin, diuretics, and aldosterone antagonists, which may be used in conjunction with isosorbide dinitrate and hydralazine 5
Racial Disparities in Treatment
There are racial disparities in the treatment of heart failure, with African American patients being less likely to receive guideline-directed medication therapy (GDMT) 7
- A study found that only 22.4% of eligible African American patients received hydralazine-isosorbide dinitrate therapy at discharge 6
- Another study found that black patients were more likely to be admitted for heart failure than white patients, despite no differences in the prescribing of GDMT or proportion of patients not on GDMT at recommended doses 7
Key Findings
- The combination of isosorbide dinitrate and hydralazine has been shown to improve survival in African American patients with heart failure and reduced ejection fraction 4, 5, 6
- African American patients with heart failure have a higher burden of cardiovascular disease and are more likely to suffer serious consequences from the disease 8, 7
- There is a need for improved ways to facilitate the use of guideline-recommended therapies in African American patients with heart failure and reduced ejection fraction 6, 7