The American College of Cardiology (ACC) published a 2021 update to its 2017 Expert Consensus Decision Pathway (ECDP) for Optimization of Heart Failure (HF) Treatment in the Journal of the American College of Cardiology. In this document, 10 issues identified as crucial for optimal management of HF with reduced ejection fraction (HFrEF) are covered, with a focus on novel therapies.
The original 2017 ECDP statement aimed to be used as a practical resource to aid clinicians in the management of patients with HFrEF. During the 4 years since its publication, several therapeutic advances (eg, angiotensin receptor-neprilysin inhibitors [ARNIs] and sodium-glucose contransporter-2 [SGLT2] inhibitors, and mitral regurgitation [MR] percutaneous therapy), along with research findings have prompted an update to these recommendations.
In 2017, the writing group identified 10 pivotal HFrEF issues demanding attention, including evidence-based, guideline-directed treatments, optimization of multidrug therapy and clinical assessment, HF specialist referral, care coordination challenges, medication adherence, specific patient cohorts, costs of and access to HF medications, the growing complexity of HF, common comorbidities, and palliative and/or hospice care.
For this update, a multidisciplinary panel of experts performed a literature review to gather the most current information available involving care of patients with HF, with a focus on HFrEF (ie, left ventricular ejection fraction ≤40%). The committee was interested in evidence-based therapeutic approaches and offered recommendations with the assumption that practitioners would consult appropriate specialists to inform clinical decision-making.
Although angiotensin-converting enzyme inhibitors (ACEIs), beta blockers, aldosterone antagonists, loop diuretics, ivabradine, hydralazine/isosorbide dinitrate (HYD/ISDN) and angiotensin receptor blockers (ARBs) all remain standard components of the HF armamentarium, the committee recommended that ARNIs play a more prominent role in HFrEF treatment going forward. In addition, SGLT2 inhibitors such as dapagliflozin and empagliflozin have been associated with clear benefits in patients with HFrEF and deserve greater consideration.
When initiating therapy in a patient with stage C HFrEF, use of an evidence-based beta blocker or medication blocking the renin-angiotensin system (ACEI/ARB/ARNI) should be used (and occasionally combined), with titration to the target or maximally tolerated dose. Treatment with an ARNI (sacubitril/valsartan) may now be started without first initiating an ACEI/ARB regimen (a washout is required in such instances). When a patient is on maximal beta blocker therapy with a heart rate (HR) still ≥70 beats/min, ivabradine, which selectively targets the sinoatrial node without impacting blood pressure, may be used to reduce HR. SGLT2 inhibitors, which have been shown to improve outcomes and reduce major events in several studies, should be weighed for inclusion, regardless of diabetes status.
Hospitalization for HFrEF may permit optimization of pharmacotherapeutic regimens. Post-discharge, guideline-directed medical therapy (GDMT) optimization efforts should continue, including up-titration to target levels and follow-up assessments. As a general rule, following HF diagnosis, GDMT should be optimized within 3 to 6 months, with up-titrations every 2 weeks, or sometimes sooner if tolerated. Ventricular function should be reassessed 3 to 6 months after reaching target levels.
When HFrEF is a result of severe primary chronic MR, surgical percutaneous repair is indicated. To achieve the best results, GDMT should ideally be optimized prior to referral for surgery, so that patients can achieve the best outcomes.
In patients on multidrug HFrEF regimens, achievement of GDMT target (or maximally tolerated) doses is essential, with dose adjustments every 2 weeks. For certain patients, particularly the elderly, abnormal renal function or medication side effects (eg, hypotension), may limit the ability to reach target levels. In such cases, clinicians should aim to prescribe lower doses of multiple medications rather than higher doses of only 1 or 2 agents, and should closely monitor volume status. In those patients, clinical follow-up should occur every 3 to 6 months, and cardiac rehabilitation should be considered. Virtual appointments have become commonplace during the COVID-19 pandemic. An echocardiogram with strain imaging should be used for HFrEF diagnosis and after GDMT optimization to assess device therapy needs, although routine surveillance in the absence of clinical changes is unnecessary. Biomarker measurement of B-type natriuretic peptide (BNP) and NT-proBNP should be used for diagnosis and prognosis of HFrEF and may also be useful for monitoring GDMT responses and determining the need for imaging and advanced referrals. Although invasive hemodynamic monitoring can be useful in certain scenarios, novel solutions for measuring filling pressures (eg, implantable sensors) may also play a role going forward.
Referrals to an HF specialist should be determined with the aid of the acronym “I NEED HELP”, referring to high risk disease features: IV inotropes; NYHA IIIB/IV; End-organ dysfunction; EF ≤35%; Defibrillator shocks; Hospitalizations >1; Edema on maximal diuretics; Low blood pressure with tachycardia; and Prognostic medication.
Many patients with HF have extensive cardiac and noncardiac comorbidities that can complicate the already complex goal of HF therapeutic optimization. Multiple clinicians providing care in a variety of settings can lead to miscommunication, treatment inefficiencies and greater risks for avoidable errors and interactions. Therefore, in this population, patient-centered care and shared decision-making should be priorities. Practitioners should adopt a team-based approach with a focus on care coordination for multiple comorbidities. Technologies such as electronic health records, monitoring devices, wearable activity monitors, and mobile devices offer potential benefits for HF treatment, but also present certain challenges.
The success of GDMT is closely linked to medication adherence, and nonadherence—driven by factors related to the patient, disease, treatment, health system, or socioeconomic issues—has been associated with poorer outcomes. Regular assessments of adherence can help tailor interventions to increase therapeutic compliance. Such interventions include patient education, medication management, pharmacist consultation, cognitive behavioral therapy, medication reminders, and financial or other incentives.
For African Americans, the elderly and the frail, there may be unique treatment considerations. However, for the most part, these 3 groups should receive the same treatments as other patients with HFrEF. An isosorbide dinitrate/hydralazine combination plays an important role in HF therapy in African Americans. Also, elderly patients often require lower medication dosages and/or may not achieve target levels.
Managing HF medication costs and ensuring access are important for maintaining high levels of care, especially considering the high prices attached to many of them. Some suggested strategies for controlling costs include care coordination, considerations of medication coverage limits, prescription of generic equivalents whenever available, use of Patient Assistance Programs, price matching requests, and use of price checking tools.
The authors identified 12 pathophysiologic targets for HF, and 11 guiding principles to help practitioners achieve optimal patient outcomes. These principles include the use of GDMT and target doses, volume status monitoring, and consideration of device therapies or transcatheter MR repair.
Multiple concomitant comorbidities in many patients require careful consideration of diagnoses and therapies in addition to evidence-based GDMT for HF. Diabetes which is a common HF comorbidity, can negatively impact outcomes. SGLT2 inhibition may improve these outcomes.
Finally, palliative and hospice care for patients with severe disease should be guided by 7 basic principles: reduction of suffering, close management of HF therapies (particularly diuretics) to control symptoms, consultations with palliation specialists, use of decision support tools, shared decision-making (with annual reassessments), clinical trajectory attention and modification of expectations, and planning for and transitioning to “comfort only” care.
“Most importantly, the checklists and algorithms provided in this ECDP should be applied only in the context of the most recent update to the AHA/ACC guidelines for management of adults with chronic HF and, in this case, patients with HFrEF. No guideline, pathway, or algorithm should ever supersede clinical judgment,” noted the authors.
Maddox TM, Januzzi JL, Allen LA, et al. 2021 update to the 2017 ACC Expert Consensus Decision Pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. January 2021. doi:10.1016/j.jacc.2020.11.022