The American College of Cardiology (ACC) released an Expert Consensus Decision Pathway for optimizing heart failure (HF) treatment, focusing on HF with reduced ejection fraction (HFrEF).
As the ACC Task Force authors explained, the updated 2017 HF guidelines represent a “focused update” of the 2013 HF guidelines, with a new treatment algorithm based on new evidence that supports novel drug therapies.
Currently, a clinician treating a patient with HFrEF may choose from “no fewer than 7 evidence-based medications, 3 evidence-based device strategies, and a number of recommended processes of care.” As the authors point out, “with more choices comes greater complexity.” Thus, they set out to address 10 pivotal issues in HFrEF:
- Initiating, adding, or switching of therapy to new evidence-based, guideline-directed treatments for HFrEF
- Achieving optimal therapy with multiple drugs for HF that may trigger additional changes in guideline-directed therapy (eg, imaging data, biomarkers, and filling pressures)
- When to refer to an HF specialist
- Addressing care coordination challenges
- Improving adherence
- Addressing the needs of specific patient cohorts
- Managing patients’ cost of care
- Managing the increasing complexity of HF
- Managing common comorbidities
- Integrating palliative care and transition to hospice care
The authors detailed appropriate scenarios for treating HFrEF with beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNIs), as well as tools to evaluate the titration and maintenance of medications. A patient should be referred to a specialist when any one of the following is present: persistent or worsening symptoms, adverse clinical events, or other signs that there is a high risk for disease progression or death.
In terms of overcoming the challenges of care coordination, the authors suggested that “team-based care may be the most effective approach to HF care.” An HF team should be proficient in diagnosing and monitoring the disease, educating both the patient and caregivers, addressing lifestyle issues (eg, diet and exercise), providing psychological and social support, and coordinating care for comorbidities, among other skills.
Considering cost and access to medication, simplifying medication regimens, and anticipating problems with medications (eg, side effects, instructions for refills) are among several guidelines for improving adherence. The authors highlighted African Americans, frail adults, and older adults as specific patient populations that may need special consideration, such as the risk for angioedema in African-American patients who are taking ACEIs or ARNIs, being mindful of the upper age limits of most clinical trials (75 ± 5 years), and noting that frailty increases the risk for HF and potentially, morbidity and mortality.
Costs may be reduced by choosing generic over name-brand drugs, requesting “price matching” from pharmacies, and splitting medications (without reducing doses) when appropriate.
For managing the complexity of HF, the authors outlined 10 principles to improve patient outcomes: target dosing, address factors limiting guideline-directed medical therapy, achieve optimal sympathetic nervous system modulation with target doses of beta-blockers, heart rate-lowering medications may not have the same effect, African-American patients may derive more benefit from hydralazine/isosorbide dinitrate therapy, device and cardiac resynchronization therapy should only be considered after optimal doses of medications have been used for 3 to 6 months, optimize team-based care, be aware that tolerability and side effects may be affected by how and when therapy is given, and focus on the patients’ symptoms and functional capacity as well as improving cardiac function.
“[T]he checklists and algorithms provided in this Decision Pathway should be applied only in the context of the most recent update to the AHA/ACC guideline for management of adults with chronic HF, and in this case, patients with HFrEF,” the authors concluded. “No guideline, pathway, or algorithm should ever supersede clinical judgment.”
Yancy CW, Januzzi JL Jr, Allen LA, et al. 2017 ACC Expert Consensus Decision Pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2018;71:201-230.