What are the management strategies for outpatient heart failure?

From the Guidelines

Outpatient heart failure management should prioritize guideline-directed medical therapy (GDMT) to reduce morbidity, mortality, and improve quality of life, as recommended by the 2024 update to the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1. The cornerstone of GDMT includes medications such as ARN inhibitors, ACE inhibitors, ARBs, evidence-based beta blockers, MRAs, and SGLT2 inhibitors, which should be continued in the outpatient setting to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic. Key aspects of outpatient management include:

• Medication therapy: ACE inhibitors (like lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily), beta-blockers (metoprolol succinate 25-200mg daily or carvedilol 3.125-25mg twice daily), and diuretics (furosemide 20-80mg daily or as needed) to manage fluid overload
• Lifestyle modifications: sodium restriction (<2g daily), fluid restriction (1.5-2L daily in severe cases), daily weight monitoring, regular physical activity, and smoking cessation
• Regular monitoring: patients should follow up every 1-3 months with more frequent visits during medication adjustments, and should be educated to recognize worsening symptoms like increased shortness of breath, weight gain >2kg in 3 days, or increased swelling Implementing GDMT can be facilitated through various strategies, including multidisciplinary care teams, virtual consult teams, and remote algorithm-based titration of GDMT, as supported by recent studies 1. A systematic review of randomized controlled trials found that nurse-led titration and collaboration with HF pharmacists can improve GDMT use, titration, and adherence, as well as patient-reported quality of life, among HF patients 1. Overall, a comprehensive approach to outpatient heart failure management, prioritizing GDMT and lifestyle modifications, can reduce symptoms and hospitalizations while improving quality of life and survival, as recommended by the latest guidelines 1.

From the FDA Drug Label

The Systolic Heart Failure Treatment with the I f Inhibitor Ivabradine Trial (SHIFT) was a randomized, double-blind trial comparing ivabradine and placebo in 6,558 adult patients with stable New York Heart Association (NYHA) class II to IV heart failure, left ventricular ejection fraction ≤ 35%, and resting heart rate ≥ 70 bpm Patients had to have been clinically stable for at least 4 weeks on an optimized and stable clinical regimen, which included maximally tolerated doses of beta-blockers and, in most cases, ACE inhibitors or ARBs, spironolactone, and diuretics, with fluid retention and symptoms of congestion minimized. SHIFT demonstrated that ivabradine reduced the risk of the combined endpoint of hospitalization for worsening heart failure or cardiovascular death based on a time-to-event analysis (hazard ratio: 0.82,95% confidence interval [CI]: 0.75,0.90, p < 0. 0001)

Ivabradine can be used in the management of heart failure in outpatient settings for patients with stable NYHA class II to IV heart failure, left ventricular ejection fraction ≤ 35%, and resting heart rate ≥ 70 bpm. The treatment should be initiated and monitored by a healthcare provider, with the goal of reducing the risk of hospitalization for worsening heart failure. Key components of the treatment regimen include:

• Optimized and stable clinical regimen, which may include:
  • Beta-blockers at maximally tolerated doses
  • ACE inhibitors or ARBs
  • Spironolactone
  • Diuretics
• Ivabradine dosing, which should be adjusted to maintain a resting heart rate between 50 and 60 bpm, as tolerated 2.

From the Research

Heart Failure Management in Outpatient Settings

Heart failure management in outpatient settings involves various approaches, including:

• Guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) 3
• Use of cardiac rhythm management (CRM) devices, such as implantable cardioverter-defibrillators and cardiac resynchronization therapy, to reduce mortality and morbidity in patients with HFrEF 4
• Patient-centered care, including shared decision-making and personalized treatment plans 4

Treatment Patterns in Outpatient Settings

Studies have shown that:

• Use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and beta-blockers is relatively high in eligible patients in outpatient cardiology settings 5
• Other treatments, such as aldosterone antagonists, device therapy, and patient education, have lower rates of use 5
• There is significant variation among cardiology practices in the use of guideline-recommended therapies for heart failure patients 5

Management of Heart Failure with Improved Ejection Fraction

For patients with heart failure with improved ejection fraction (HFimpEF):

• Current guidelines recommend sustained and indefinite GDMT 6
• Emerging evidence suggests that de-escalation of GDMT may be safe and feasible in select patients with specific etiologies 6
• Further studies are needed to investigate the use of advanced imaging and blood biomarkers to risk-stratify patients with recovered left ventricular ejection fraction (LVEF) and to determine the safety and feasibility of partial de-escalation of GDMT 6

Recent Guideline Updates

The 2022 guideline from the American College of Cardiology, American Heart Association, and Heart Failure Society of America provides practical recommendations for managing patients with HFrEF, including updates on GDMT and device therapy 7