What are the recent guidelines for managing Congestive Heart Failure (CHF)?

From the Guidelines

Recent guidelines for managing Congestive Heart Failure (CHF) prioritize a comprehensive approach including medications, lifestyle modifications, and monitoring, with a focus on reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, the 2024 ESC guidelines for the management of chronic coronary syndromes 1, recommends that patients with CHF be enrolled in a multidisciplinary HF management programme to reduce the risk of HF hospitalization and to improve survival.

Medications

First-line pharmacological therapy typically includes:

• An ACE-I, an MRA, an SGLT2 inhibitor (dapagliflozin or empagliflozin), and, in stable conditions, a beta-blocker for patients with HFrEF to reduce the risk of HF hospitalization and death 1.
• An SGLT2 inhibitor (dapagliflozin or empagliflozin) for patients with HF with mildly reduced ejection fraction (HFmrEF) or HFpEF to reduce the risk of HF hospitalization or cardiovascular death 1.
• An ARB in symptomatic patients with CCS and HFrEF unable to tolerate an ACE-I or ARNI to reduce the risk of HF hospitalization and cardiovascular death 1.
• Sacubitril/valsartan as a replacement for an ACE-I or ARB in CCS patients with HFrEF to reduce the risk of HF hospitalization and death 1.
• Diuretics in CCS patients with HF and signs and/or symptoms of congestion to alleviate symptoms, improve exercise capacity, and reduce HF hospitalizations 1.

Device Therapy

The guidelines also recommend:

• An ICD to reduce the risk of sudden death and all-cause mortality in patients with symptomatic HF (NYHA class II–III) of ischaemic aetiology, and an LVEF ≤35% despite ≥3 months of optimized GDMT 1.
• CRT for CCS patients with symptomatic HF, sinus rhythm, LVEF ≤35% despite GDMT, and a QRS duration ≥150 ms with an LBBB QRS morphology to improve symptoms and survival and to reduce morbidity 1.

Lifestyle Modifications and Monitoring

Lifestyle modifications include:

• Sodium restriction
• Fluid restriction
• Daily weight monitoring
• Regular physical activity as tolerated
• Smoking cessation Regular monitoring of renal function, electrolytes, and clinical symptoms is essential, with dose adjustments based on patient response.

The 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1 provides further guidance on triggers for HF patient referral to a specialist/program, including new-onset HF, chronic HF with high-risk features, and persistently reduced LVEF despite GDMT. However, the 2024 ESC guidelines 1 take precedence due to their recency and focus on CHF management.

From the FDA Drug Label

The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF) PARADIGM-HF demonstrated that sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to and RAS inhibitor (enalapril), in reducing the risk of the combined endpoint of cardiovascular death or hospitalization for heart failure, based on a time-to-event analysis (hazard ratio [HR] 0.80; 95% confidence interval [CI], 0.73,0.87, p <0. 0001)

The recent guidelines for managing Congestive Heart Failure (CHF) may include the use of sacubitril and valsartan as a treatment option to reduce the risk of cardiovascular death or hospitalization for heart failure. Key points to consider:

• Patient selection: Patients with symptomatic chronic heart failure (NYHA class II-IV) and systolic dysfunction (left ventricular ejection fraction ≤ 40%) may be eligible for this treatment.
• Dosing: The recommended dose is 200 mg twice daily, after a sequential single-blind run-in period.
• Benefits: Sacubitril and valsartan have been shown to reduce the risk of cardiovascular death or hospitalization for heart failure, and improve overall survival.
• Reference: 2

From the Research

Recent Guidelines for Managing Congestive Heart Failure (CHF)

• The renin-angiotensin-aldosterone system (RAAS) plays a key role in the pathophysiology of CHF, and inhibitors of angiotensin-converting enzyme (ACE) improve symptoms and survival in patients with CHF 3.
• First-line therapy for CHF should include an ACE inhibitor and a beta-adrenoceptor antagonist, with the addition of an angiotensin receptor antagonist (ARB) providing symptomatic relief but not improving survival 3.
• Where an ACE inhibitor is not tolerated, treatment with an ARB would seem an appropriate alternative 3.
• ACE inhibitors remain first-line therapy in patients with CHF due to systolic dysfunction, but in patients not able to tolerate ACE inhibitor-induced side effects, AT1 receptor antagonism is a good alternative 4.

Utilization of ACE Inhibitors in CHF

• Despite abundant evidence to support their efficacy and cost-effectiveness, ACE inhibitors are sub-optimally used in patients with CHF, with studies documenting that only 33% to 67% of patients discharged from hospital and 10% to 36% of community-dwelling patients were prescribed ACE inhibitors 5.
• Factors predicting the use and optimal dose administration of ACE inhibitors include variables relating to the setting, physician, patient, and drug, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment 5.
• The dosages used in the 'real world' are substantially lower than those proven efficacious in randomized, controlled trials, with evaluations reporting only a minority of patients achieving target doses 5.

Determinants of ACE Inhibitor Prescription

• Social, demographic, laboratory, clinical, and therapeutic factors associated with non-prescription of ACE inhibitors and/or their prescription at doses below those recommended include patient age, renal impairment, nonsinus cardiac rhythm, and prescription of potassium-sparing diuretics 6.
• Renal impairment is the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients 6.
• CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure to optimize and better use of ACE inhibitor therapy 6.