What is the gold standard of treatment for a patient with severe chronic heart failure (CHF)?

From the Guidelines

The gold standard treatment for severe chronic heart failure is a comprehensive approach that includes both pharmacological and non-pharmacological interventions, with sacubitril/valsartan being recommended as a replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA, as stated in the 2020 European Journal of Heart Failure guideline-directed medical therapy for heart failure 1.

Key Components of Treatment

• Inhibitors of the renin–angiotensin system, such as ACE inhibitors or ARBs, are essential for reducing cardiac workload and improving cardiac remodeling 1.
• Neprilysin inhibitors, such as sacubitril/valsartan, have been shown to reduce the risk of HF hospitalization and death in patients with HFrEF, and are recommended as a replacement for ACE-I in symptomatic patients despite optimal treatment with an ACE-I, a beta-blocker, and an MRA 1.
• Beta-adrenergic blockers, such as carvedilol, metoprolol succinate, and bisoprolol, have been shown to prolong life and reduce the risk of sudden death in patients with HFrEF 1.
• Mineralocorticoid receptor antagonists, such as spironolactone or eplerenone, are also essential for reducing mortality and morbidity in patients with HFrEF 1.
• Diuretics, such as furosemide, are recommended for symptom relief in patients with signs and/or symptoms of congestion 1.

Additional Considerations

• Sodium-glucose cotransporter-2 (SGLT2) inhibitors, such as dapagliflozin or empagliflozin, have shown significant mortality benefits in patients with HFrEF, but their use is still evolving and not yet widely established as part of the gold standard treatment 1.
• Device therapy, including cardiac resynchronization therapy (CRT), implantable cardioverter-defibrillators (ICDs), and left ventricular assist devices (LVADs), may be indicated in advanced cases of heart failure 1.
• Heart transplantation remains the definitive treatment for end-stage heart failure in eligible candidates.

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 gold standard of treatment for patients with severe chronic heart failure is sacubitril and valsartan, as it has been shown to be superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure, based on the results of the PARADIGM-HF trial 2.

• Key benefits of sacubitril and valsartan include:
  • Reduced risk of cardiovascular death
  • Reduced risk of heart failure hospitalization
  • Improved overall survival

From the Research

Treatment Options for Severe Chronic Heart Failure

• The gold standard treatment for severe chronic heart failure is heart transplantation after failure of medical therapy, surgery, and/or cardiac resynchronisation therapy 3.
• Other treatment options include mechanical cardiac support devices, such as left ventricular assist devices, which are considered promising 3.
• Structured care for heart failure patients according to international heart failure guidelines can contribute to optimal decision-making 3.

Medical Therapy for Heart Failure

• Therapy with angiotensin-converting enzyme inhibitors, beta-blockers, and diuretics is considered standard for the treatment of heart failure 4.
• Digoxin may be added to improve clinical symptoms, especially in patients with atrial fibrillation 4.
• Aldosterone antagonists may be recommended in select patients with stable New York Heart Association class III or IV heart failure 4.
• Angiotensin receptor blockers, hydralazine hydrochloride, and isosorbide dinitrate may be recommended if angiotensin-converting enzyme inhibitors are not tolerated 4.

Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers

• Continued use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in patients with heart failure with reduced ejection fraction is associated with lower mortality risk and reduced hospital readmissions 5.
• The use of sacubitril/valsartan may be beneficial for patients with heart failure with reduced ejection fraction, especially in those who do not respond to traditional medications 6.

Management of Chronic Heart Failure

• Optimal therapy for chronic heart failure involves identification and correction of potentially reversible precipitants, target-dose titration of medical therapy, and management of hospitalizations for decompensation 7.
• Patients who transition to advanced stages of disease despite optimal traditional medical and device therapy may be candidates for hemodynamically directed approaches, such as left ventricular assist devices, or cardiac transplant 7.