What is the best approach for complex medical management of a patient with multiple conditions, such as heart failure, and what medications, like ACE (Angiotensin-Converting Enzyme) inhibitors, beta-blockers, and ARNI (Angiotensin Receptor-Neprilysin Inhibitor), should be used?

From the Guidelines

The best approach for complex medical management of a patient with multiple conditions, particularly heart failure, involves a comprehensive, guideline-directed medical therapy (GDMT) that typically includes a combination of ACE inhibitors or ARNIs, beta-blockers, and mineralocorticoid receptor antagonists. For patients with heart failure with reduced ejection fraction (HFrEF), an ARNI such as sacubitril/valsartan (Entresto) is preferred over ACE inhibitors when possible, starting at 24/26 mg twice daily and titrating to 97/103 mg twice daily as tolerated, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Beta-blockers like carvedilol (starting at 3.125 mg twice daily, target 25 mg twice daily), metoprolol succinate (starting at 12.5-25 mg daily, target 200 mg daily), or bisoprolol (starting at 1.25 mg daily, target 10 mg daily) should be initiated at low doses and gradually increased, as supported by the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1. Mineralocorticoid receptor antagonists such as spironolactone (25-50 mg daily) or eplerenone (25-50 mg daily) should be added for patients with NYHA class II-IV symptoms, as indicated in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Diuretics like furosemide (20-80 mg daily or twice daily) should be used as needed for fluid overload, and for patients who remain symptomatic, SGLT2 inhibitors like dapagliflozin (10 mg daily) or empagliflozin (10 mg daily) have shown benefit, as noted in the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1. This stepwise approach targets multiple pathophysiological mechanisms in heart failure, including the renin-angiotensin-aldosterone system and sympathetic nervous system, while monitoring for side effects such as hypotension, hyperkalemia, and worsening renal function, as emphasized in the 2013 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1. Regular follow-up with dose adjustments based on clinical response, renal function, and electrolyte levels is essential for optimizing therapy, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

Some key points to consider in the management of heart failure include:

• The use of ACE inhibitors or ARNIs to reduce morbidity and mortality, as supported by the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1
• The addition of beta-blockers to reduce hospitalizations and improve symptoms, as indicated in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1
• The use of mineralocorticoid receptor antagonists to reduce morbidity and mortality in patients with NYHA class II-IV symptoms, as recommended by the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1
• The importance of regular follow-up and dose adjustments to optimize therapy and minimize side effects, as emphasized in the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

Overall, a comprehensive and guideline-directed approach to the management of heart failure is essential to improve outcomes and reduce morbidity and mortality, as supported by the evidence from multiple studies and guidelines 1.

From the FDA Drug Label

5.4 Impaired Renal Function As a consequence of inhibiting the renin-angiotensin-aldosterone system (RAAS), decreases in renal function may be anticipated in susceptible individuals treated with sacubitril and valsartan [see Adverse Reactions (6.1)]. In patients whose renal function depends upon the activity of the renin-angiotensin-aldosterone system (e.g., patients with severe congestive heart failure), treatment with ACE inhibitors and angiotensin receptor antagonists has been associated with oliguria, progressive azotemia and, rarely, acute renal failure and death Closely monitor serum creatinine, and down-titrate or interrupt sacubitril and valsartan in patients who develop a clinically significant decrease in renal function [see Use in Specific Populations (8.7) and Clinical Pharmacology (12. 3)].

The best approach for complex medical management of a patient with multiple conditions, such as heart failure, involves careful consideration of the potential risks and benefits of medications like ACE inhibitors, beta-blockers, and ARNI (Angiotensin Receptor-Neprilysin Inhibitor).

• Key considerations include:
  • Monitoring renal function closely, especially in patients with pre-existing renal impairment
  • Adjusting medication doses or interrupting treatment as needed to minimize the risk of adverse effects
  • Weighing the potential benefits of treatment against the risks, particularly in patients with severe congestive heart failure
  • Considering alternative treatment options when necessary, such as in patients with a history of angioedema or hyperkalemia 2 2. Medications such as sacubitril and valsartan may be used in the management of heart failure, but require careful monitoring and dose adjustment to minimize the risk of adverse effects.

From the Research

Complex Medical Management Approach

• A multidisciplinary team approach is recommended for managing patients with complex medical conditions, such as heart failure 3, 4, 5.
• This approach involves a team of healthcare professionals, including cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians, working together to provide comprehensive care 4.
• The multidisciplinary team approach has been shown to decrease hospitalization rates, improve adherence to self-care and guideline-directed medical therapy, and reduce healthcare costs 4.

Medications for Heart Failure Management

• Angiotensin-Converting Enzyme (ACE) inhibitors, beta-blockers, and Angiotensin Receptor-Neprilysin Inhibitors (ARNI) are commonly used medications for managing heart failure 6, 7.
• ARNI therapy, such as sacubitril/valsartan, has been shown to promote diuresis in heart failure patients and may reduce the need for diuretic therapy 6.
• The coadministration of furosemide with sacubitril/valsartan may affect the pharmacokinetics and pharmacodynamics of furosemide, and careful monitoring is recommended 7.

Benefits of Multidisciplinary Team Approach

• Improved care coordination and communication among healthcare team members 4, 5.
• Enhanced patient satisfaction and outcomes 4.
• Better management of complex medical conditions, such as heart failure, and reduction of hospitalization rates and healthcare costs 4.