What are the Philippine guidelines for managing heart failure with reduced ejection fraction (HFrEF)?

Philippine Guidelines for Managing Heart Failure with Reduced Ejection Fraction (HFrEF)

The Philippine guidelines for managing HFrEF follow international standards recommending a comprehensive quadruple therapy approach with ACEI/ARB/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors as core treatments for all eligible patients with HFrEF to reduce mortality and hospitalizations. 1

Classification and Diagnosis

• HFrEF is defined as clinical heart failure syndrome with left ventricular ejection fraction (LVEF) ≤40% 1
• Diagnosis requires typical symptoms (breathlessness, ankle swelling, fatigue), signs (elevated jugular venous pressure, pulmonary crackles, peripheral edema), and evidence of structural/functional cardiac abnormality resulting in reduced cardiac output 1

Core Pharmacological Therapy for HFrEF

First-Line Quadruple Therapy

• Renin-Angiotensin System Inhibitors: ACEI/ARB or preferably ARNI (sacubitril/valsartan) 1
• Evidence-based Beta-blockers: Carvedilol, metoprolol succinate, or bisoprolol 1
• Mineralocorticoid Receptor Antagonists (MRAs): Spironolactone or eplerenone 1
• SGLT2 Inhibitors: Dapagliflozin or empagliflozin - recommended regardless of diabetes status 1
• Diuretics: As needed for congestion and symptom relief 1, 2

Unique Advantages of SGLT2 Inhibitors

• Do not affect blood pressure, heart rate, or potassium levels 1
• Require no dose adjustment or up-titration 1
• Beneficial in patients with moderate kidney dysfunction (eGFR ≥20-30 ml/min/1.73 m²) 1
• Provide early benefits (within weeks) regardless of age, sex, or background therapy 1

Additional Therapies for Specific Scenarios

• Ivabradine: For patients with LVEF ≤35%, sinus rhythm with resting heart rate ≥70 bpm, and either on maximally tolerated beta-blockers or with beta-blocker contraindication 3
• Vericiguat: Consider for patients with recent HF hospitalization or IV diuretic treatment who remain symptomatic despite optimal therapy with foundational medications 4
• Intravenous Iron: Recommended for patients with iron deficiency to improve functional status 5
• Hydralazine/Isosorbide Dinitrate: For selected patients with persistent symptoms 5

Implementation Strategy

• Simultaneous Initiation Approach: Start core medications together rather than sequential step-by-step approach 1
• Dose Adjustments: Modify based on blood pressure, heart rate, congestion, kidney function, and presence of atrial fibrillation 1
• Target Doses: Aim to reach guideline-recommended target doses within 6-12 weeks of diagnosis 5, 6

Management of Low Blood Pressure

• Asymptomatic low BP should not be a barrier to GDMT initiation or maintenance 1
• For symptomatic low BP (SBP <80 mmHg):
  • Address reversible non-HF causes of hypotension 1
  • Consider temporary discontinuation of non-HF medications that lower BP 1
  • Re-optimize GDMT with careful dose adjustments 1

Device Therapies When Appropriate

• Implantable Cardioverter Defibrillator (ICD): For primary prevention in selected patients 2, 5
• Cardiac Resynchronization Therapy (CRT): For patients with prolonged QRS duration 1, 5
• Transcatheter Mitral Valve Repair: For selected patients with significant secondary mitral regurgitation 1, 5

Common Challenges and Solutions

• Clinical Inertia: Establish structured follow-up protocols to ensure timely initiation and up-titration 1
• Medication Adherence: Provide patient education about the importance of adherence even when feeling better 1, 2
• Monitoring: Regular assessment of renal function, electrolytes, blood pressure, and heart rate 5, 6
• Comorbidity Management: Address common comorbidities that can worsen HF outcomes 7, 5

Special Considerations for HF with Mildly Reduced EF (HFmrEF, LVEF 41-49%)

• SGLT2 inhibitors are beneficial in decreasing HF hospitalizations and cardiovascular mortality 1
• Consider evidence-based beta-blockers, ARNI, ACEI/ARB, and MRAs, particularly for patients with LVEF on the lower end of this spectrum 1