What is the optimal management for a patient with Heart Failure (HF) and Atherosclerotic Cardiovascular Disease (ASCVD)?

Optimal Management of Heart Failure with Atherosclerotic Cardiovascular Disease

Patients with both heart failure and ASCVD require comprehensive guideline-directed medical therapy (GDMT) for heart failure combined with aggressive lipid management and antiplatelet therapy to reduce both heart failure progression and atherothrombotic events.

Core Pharmacological Management for HFrEF (LVEF ≤40%)

Foundation Therapy (Start All Four Simultaneously When Possible)

• ACE inhibitors or ARBs are mandatory for all patients with current or prior HF symptoms and reduced LVEF unless contraindicated, to reduce morbidity and mortality 1, 2

• If ACE inhibitor intolerant due to cough or angioedema, use ARBs as the alternative 1

• Consider switching to sacubitril/valsartan (ARNI) in patients who remain symptomatic despite optimal ACE inhibitor/ARB therapy, as this provides additional 20% relative risk reduction in cardiovascular death and hospitalization 2

• Beta-blockers (only bisoprolol, carvedilol, or sustained-release metoprolol succinate) are required for all stable patients with current or prior HF symptoms and reduced LVEF 1, 2

• These three specific agents have proven mortality reduction; other beta-blockers lack this evidence 2

• SGLT2 inhibitors (dapagliflozin or empagliflozin) are now cornerstone therapy for all HFrEF patients regardless of diabetes status, reducing HF hospitalization and cardiovascular death 1, 3

• This represents a major advancement in HF management with Class I, Level A evidence 1

• Mineralocorticoid receptor antagonists (spironolactone 12.5-25 mg daily, maximum 50 mg) should be added in patients with NYHA class II-IV symptoms, preserved renal function, and normal potassium 1

Diuretic Management for Congestion

• Loop diuretics are indicated for all patients with current or prior symptoms and evidence of fluid retention 1, 4
• Start furosemide 20-40 mg once or twice daily (maximum 600 mg), bumetanide 0.5-1.0 mg once or twice daily (maximum 10 mg), or torsemide 10-20 mg once daily (maximum 200 mg) 1
• Torsemide has the longest duration of action (12-16 hours) and may provide more consistent diuresis 1

ASCVD-Specific Management

• High-intensity statin therapy is mandatory for all patients with recent or remote history of MI or ACS to prevent symptomatic HF and reduce adverse cardiovascular events 1

• Atorvastatin 80 mg daily reduced major cardiovascular events by 22% (HR 0.78, p=0.0002) compared to 10 mg daily in the TNT trial, including significant reductions in non-fatal MI and stroke 5

• This aggressive lipid management is critical as ASCVD patients with HF face dual pathophysiologic threats 5

• Antiplatelet therapy should continue in patients with established ASCVD, though specific recommendations must balance ischemic and bleeding risks 6

Medications to AVOID in HFrEF

• Nondihydropyridine calcium channel blockers (diltiazem, verapamil) are contraindicated as they have negative inotropic effects and may worsen outcomes 1, 4
• NSAIDs should be avoided or withdrawn as they cause sodium retention, worsen fluid status, and blunt diuretic effects 1
• Thiazolidinediones must not be used in patients with LVEF <50% as they increase HF risk and hospitalizations 1, 4
• Most antiarrhythmic drugs should be avoided due to adverse effects on clinical status 1

Device Therapy Considerations

ICD for Primary Prevention

• Recommended for patients with LVEF ≤35% (or ≤30% if >40 days post-MI), NYHA class II-III symptoms on optimal medical therapy, and life expectancy >1 year with good functional status 1, 2
• This provides secondary prevention for sudden cardiac death in this high-risk population 1

Cardiac Resynchronization Therapy (CRT)

• Indicated for patients with LVEF ≤35%, sinus rhythm, QRS ≥150 ms with LBBB morphology, and NYHA class II-IV symptoms despite GDMT 1, 2, 4
• CRT with or without ICD is reasonable for patients with atrial fibrillation meeting similar criteria 1

Atrial Fibrillation Management (Common Comorbidity)

• Chronic anticoagulation is required for all HF patients with permanent-persistent-paroxysmal AF and CHA₂DS₂-VASc score ≥2 (men) or ≥3 (women) 1
• Direct oral anticoagulants (DOACs) are preferred over warfarin in eligible patients 1
• AF ablation is reasonable for patients with HF and symptoms caused by AF to improve symptoms and quality of life 1
• Diuretics are specifically recommended in patients with AF, HF, and congestion to alleviate symptoms and facilitate better AF management 1

Uptitration Strategy

• Start medications at low doses and uptitrate gradually every 1-2 weeks, alternating between ACE inhibitor/ARB and beta-blocker adjustments 2
• Go slower in elderly patients or those with chronic kidney disease 2
• Target maximum tolerated doses of all GDMT medications rather than stopping at arbitrary intermediate doses 2

Non-Pharmacological Management

• Exercise training or regular physical activity is beneficial as adjunctive therapy to improve clinical status in ambulatory patients 1, 4
• Sodium restriction is reasonable for symptomatic patients to reduce congestive symptoms 1
• Multidisciplinary HF management programs should be utilized to reduce HF hospitalizations and improve survival 7, 4
• Patient education on self-care, daily weight monitoring, medication adherence, and symptom recognition is essential 7, 2

Critical Pitfalls to Avoid

• Do not use angiotensin receptor blockers instead of ACE inhibitors in patients who have not tried or cannot tolerate ACE inhibitors—this is Class III evidence 1
• Do not start ARB before beta-blocker in patients already taking ACE inhibitor—this sequence matters 1
• Avoid routine combined use of ACE inhibitor, ARB, and aldosterone antagonist due to excessive hyperkalemia and renal dysfunction risk 1
• Do not use calcium channel blockers as treatment for HF—they provide no benefit and may cause harm 1
• Confirm diagnosis accuracy and ensure all conventional medical strategies are optimally employed before labeling a patient as having refractory HF 1

Special Considerations for ASCVD + HF Population

• These patients face elevated risk from both atherothrombotic events and HF progression, requiring dual focus 8, 9
• Icosapent ethyl reduced cardiovascular events similarly in patients with and without HF history (HR 0.87 vs 0.73, P-interaction=0.13), suggesting benefit in this population 8
• The combination of optimal HF therapy plus aggressive ASCVD risk factor modification provides additive benefits 6, 10
• Regular reassessment of volume status, medication tolerance, and disease progression is mandatory 7