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

From the Guidelines

Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) should include 4 medication classes, including sodium-glucose cotransporter-2 inhibitors (SGLT2i), as recommended by the 2022 AHA/ACC/HFSA guideline 1. The management of heart failure involves a multifaceted approach that prioritizes reducing morbidity, mortality, and improving quality of life. Key components include:

• Lifestyle modifications such as restricting sodium intake to less than 2-3g daily and limiting fluid intake to 1.5-2L daily
• Regular moderate exercise as tolerated
• Monitoring daily weights to detect fluid retention early
• First-line medications including ACE inhibitors or ARBs to reduce afterload and remodeling
• Beta-blockers to reduce workload on the heart
• Diuretics like furosemide to manage fluid overload
• For patients with ejection fraction ≤40%, consider adding an aldosterone antagonist and SGLT2 inhibitors, which have shown mortality benefits 1

Medication Classes

The 2022 AHA/ACC/HFSA guideline recommends the following medication classes for HFrEF:

• SGLT2 inhibitors (Class of Recommendation 2a)
• ACE inhibitors or ARBs
• Beta-blockers
• Aldosterone antagonists

Special Considerations

• Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF 1
• Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B) 1
• Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease, and malignancy 1

From the FDA Drug Label

14 CLINICAL STUDIES

... 14.1 Adult Heart Failure PARADIGM-HF was a multinational, randomized, double-blind trial comparing sacubitril and valsartan tablets and enalapril in 8,442 adult patients with symptomatic chronic heart failure (NYHA class II to IV) and systolic dysfunction (left ventricular ejection fraction ≤ 40%) ... The primary endpoint was the first event in the composite of CV death or hospitalization for HF.

1 INDICATIONS AND USAGE

1.1 Heart Failure in Adult Patients Ivabradine tablets are indicated to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35%, who are in sinus rhythm with resting heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use.

The guidelines for heart failure treatment with sacubitril/valsartan and ivabradine are as follows:

• Sacubitril/valsartan: Indicated for patients with symptomatic chronic heart failure (NYHA class II to IV) and systolic dysfunction (left ventricular ejection fraction ≤ 40%) 2.
• Ivabradine: Indicated to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35%, who are in sinus rhythm with resting heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use 3. Key points:
• Left ventricular ejection fraction: ≤ 40% for sacubitril/valsartan and ≤ 35% for ivabradine.
• NYHA class: II to IV for sacubitril/valsartan.
• Resting heart rate: ≥ 70 beats per minute for ivabradine.
• Beta-blocker use: Maximally tolerated doses or contraindication for ivabradine.

From the Research

Guidelines for Heart Failure

• The cornerstone of heart failure therapy includes angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers, which are indicated in virtually every patient with heart failure and reduced ejection fraction 4.
• A mineralocorticoid receptor antagonist should be added when the left ventricular ejection fraction decreases below 35% and/or symptoms are still present (NYHA II-IV) 4.
• Sacubitril/valsartan is a recent addition to heart failure therapy, indicated for patients with persistent symptomatic heart failure despite optimal medical therapy with ACE inhibitors or ARBs, beta-blockers, and MRAs 4, 5.
• Diuretics, such as loop diuretics, are important for symptom control, and achieving an optimal iron status can add to the success of medical treatment 4.
• Lifestyle changes, decreasing heart frequency with Ivabradine, and antiarrhythmic drugs like amiodarone can also be beneficial in managing heart failure 4, 6.

Treatment Strategies

• The use of ACE inhibitors is recommended as the first choice in the treatment of heart failure patients, with ARBs reserved for patients who are intolerant to ACE-Is 7.
• Sacubitril-valsartan has been shown to reduce risks of death and hospitalization for heart failure compared to ACE/ARB therapy in some patients 5.
• SGLT2 inhibitors and vericiguat have also been found to improve disease outcomes and reduce mortality in patients with heart failure 6.
• Device therapies, such as cardiac resynchronization therapy and implantable cardiac defibrillators, may be beneficial in specific subpopulations of patients with heart failure 6.

Patient Management

• Assessment for heart failure begins with obtaining a medical history and physical examination, and central to diagnosis are elevated natriuretic peptides and identification of left ventricular systolic dysfunction with LVEF of 40% or less as measured by echocardiography 6.
• Patients with heart failure with reduced ejection fraction (HFrEF) should be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy, with addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms 6.
• The management of HFrEF has seen significant scientific breakthrough in recent decades, and the ability to alter the natural history of the disease has never been better 6.