What are the current guidelines for managing Heart Failure (HF)?

From the Guidelines

The newest guidelines for managing heart failure emphasize a comprehensive approach centered on four core medication classes for patients with heart failure with reduced ejection fraction (HFrEF): SGLT2 inhibitors, angiotensin receptor-neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists, as recommended by the 2022 AHA/ACC/HFSA guideline 1. These medications should be initiated at low doses and gradually increased to target doses as tolerated. The guidelines also recommend the following:

• SGLT2 inhibitors for patients with heart failure with preserved ejection fraction (HFpEF) along with symptom management 1
• Diuretics for symptom relief
• Iron supplementation for deficiency
• Device therapies like implantable cardioverter-defibrillators for appropriate candidates
• Lifestyle modifications including sodium restriction (2-3g daily), fluid restriction when necessary, regular physical activity, and weight monitoring Key considerations in managing heart failure include:
• Identifying and addressing precipitating factors such as acute coronary syndromes, severe hypertension, and atrial and ventricular arrhythmias 1
• Monitoring for signs of hypoperfusion and congestion, and adjusting therapy accordingly 1
• Using invasive hemodynamic monitoring to guide therapy in patients with respiratory distress or impaired perfusion 1
• Continuation of guideline-directed medical therapy (GDMT) for HFrEF in most patients, unless contraindicated or in the setting of hemodynamic instability 1.

From the Research

Managing Heart Failure with Reduced Ejection Fraction

The newest guidelines on managing heart failure with reduced ejection fraction (HFrEF) emphasize the importance of practical recommendations for preventing, diagnosing, and managing patients with HFrEF 2.

Key Principles

Some key principles in managing HFrEF include:

• The use of four foundation drugs: angiotensin receptor/neprilysin inhibitor, beta-adrenergic blocking agents, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, which should be introduced over a short-term period of four to six weeks, guided by a safety protocol, followed by a dose up-titration period of 8 weeks 3.
• Sacubitril/valsartan should be preferred as first-line therapy for HFrEF, instead of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker 3.
• Rapid initiation of all four foundational therapies, followed by their titration to target doses, with emphasis on multiple simultaneous drug changes with each patient encounter 4.

Treatment Options

Treatment options for HFrEF include:

• Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, direct-acting vasodilators, beta blockers, and aldosterone antagonists, which have been shown to have a consistent mortality benefit 5.
• Diuretics and digoxin can be used as needed for symptom control 5.
• Implantable cardioverter-defibrillators and biventricular pacemakers can improve mortality and function in selected patients 5.
• Device therapy with an implantable cardioverter-defibrillator and/or cardiac resynchronization therapy may be beneficial for some patients with HFrEF 6.

Management Strategies

Management strategies for HFrEF include:

• Ensuring that all patients with HFrEF are adhering to goal-directed management and therapy within 6 months of diagnosis to reduce morbidity and mortality 6.
• Referral to a cardiology subspecialist is recommended for select patients with HFrEF 6.
• Disease management programs and telemonitoring can reduce hospitalizations and mortality in patients who have been hospitalized for heart failure 5.