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Key Takeaways From the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

What’s new in the treatment of heart failure? The 2022 AHA/ACC/HFSA Guideline for the Management was just released in the beginning of April! While much of the ground it covers might not seem particularly groundbreaking to anyone who has been paying attention to discussions on #MedTwitter, #CardioTwitter or the latest clinical trials over the last 2-3 years, it codifies the guideline directed medical therapy (GDMT) that we have all come to know and love for the treatment of heart failure with a reduced ejection fraction (HFrEF). These new guidelines also provide the first-ever guideline recommendations for patients with (heart failure with a preserved ejection fraction) HFpEF and heart failure with mildly reduced ejection fraction (HFmrEF), though the strength of recommendation for these conditions is not as strong as those for HFrEF.

Here are some key takeaways from the new heart failure guideline!

  1. Quadruple therapy GDMT for HFrEF

The latest guideline officially provides class IA recommendations for the use of the following medications in the treatment of HFrEF (defined as LVEF 40% or lower) in patients that have at least NYHA class II symptoms:

  1. Angiotensin-converting enzyme (ACE) inhibitors (ACEi) [i.e. lisinopril] or angiotensin-receptor blockers (ARBs) [i.e. losartan] or angiotensin receptor blocker/neprolysin inhibitor combination (ARNi) [i.e. sacubitril-valsartan]
  2. Beta blockers [i.e. metoprolol, carvedilol]
  3. Mineralocorticoid antagonists [i.e. spironolactone]
  4. SGLT2 inhibitors (SGLTi) [i.e. empagliflozin, dapagliflozin]

The first three classes were previously recommended for the treatment of HFrEF but prior American cardiovascular society guidelines did not include such a strong recommendation for the use of SGLT inhibitors.

  1. We now have HFimpEF

HFimpEF now refers to heart failure in someone who previously had HFrEF but whose LVEF has improved to >40%. The guideline strongly recommends continuing GDMT for patients that fall into this category.

  1. We now have HFmrEF recommendations

The guideline now provides a class 2A recommendation for the use of SGLT2i in the treatment of symptomatic HFmrEF (defined as LVEF 41-49%). It also provides class 2B recommendations for the use of ARNi/ACEi/ARB, beta blockers and MRAs in these patients. These recommendations confirm what some physicians/cardiologists have already begun doing in practice, though the level of evidence to support the use of these medications in HFmrEF as it is for patients with HFrEF.

  1. We also have new HFpEF recommendations

For the first time ever, the guideline recommends medications for the treatment of symptomatic HFpEF (defined as LVEF 50% or greater). Similar to its recommendations for the treatment of HFmrEF, it provides a class IIA recommendation for the use of SGLT2i and class 2B recommendations for beta blockers, ARNi, ACEi, ARB and MRAs, especially if the patient has an LVEF that is closer to 50%. Again, as we know, the level of evidence to support these practices is not as strong as it is for HFrEF. Still, this represents a change from previous guidelines which provided limited options for treatment of HFpEF.

  1. ICD or CRT is still recommended for primary prevention in certain cases

This guideline continues to recommend an implantable cardioverter-defibrillator (ICD)  in a subset of patients, particularly those whose LVEF remains less than or equal to 35% despite being on maximally-tolerated GDMT (there are nuances to this that we will not get into here). Similarly, as before, the guideline also continues to recommend cardiac resynchronization therapy (CRT) for patients who have an LVEF less than or equal to 35%, sinus rhythm, left bundle branch block with a QRS duration of at least 150 ms, NYHA class II-III symptoms.

  1. New recommendations for diagnosis and treatment of cardiac amyloidosis

The new guideline provides class I recommendations for checking serum and urine immunofixation electrophoresis and serum free light chains in patients (which would help diagnose AL amyloidosis) in patients for whom there is clinical suspicion for cardiac amyloidosis. Similarly, there is a class I recommendation for bone scintigraphy to evaluate for transthyretin (TTR) amyloidosis in patients for whom there is sufficient clinical suspicion for amyloidosis (left to the clinician’s judgment). Genetic testing is also recommended if a patient is diagnosed with TTR amyloidosis. For the first time, the guideline provides a class IB recommendation for the use of tafamadis in patients with transthyretin cardiac amyloidosis. And finally, the guideline gives a class IIA recommendation for use of anticoagulation in patients with concurrent atrial fibrillation and cardiac amyloidosis, regardless of CHA2DS2-VASc score.

 

“The views, opinions, and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness, and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions, or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”

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Another (Louder) Call to Improve the Care We Provide Heart Failure Patients

I am always taken aback when I recommend a switch to sacubitril/valsartan in a patient with heart failure with reduced ejection fraction (HFrEF) and the response is “my patient feels fine”. This is a common response and certainly not a good enough reason to not optimize guideline directed medical therapy (GDMT) in patients with HFrEF. Optimization of GDMT in HFrEF, known to improve morbidity and mortality (1,2), is dismal. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included patients in the United States with chronic HFrEF receiving at least one oral medication for management of HF and showed >25% of eligible patients are not prescribed angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor, >33% are not prescribed a beta blocker, >50% are not prescribed a mineralocorticoid receptor antagonist. Remarkably, even among those receiving GDMT fewer than 25% are prescribed target doses and only 1% of eligible patients are simultaneously on target doses of all 3 classes of GDMT (3,4).

The mechanisms for suboptimal prescription of GDMT in HFrEF are complex and undertreatment is even more evident among women, minority patient populations, and patients from economically disadvantaged backgrounds, among others. Cost is certainly an issue, especially with more novel HF therapies and co-pay assistance programs are not always available to our most vulnerable patients. There are not enough HF cardiologists to take care of the continuously increasing population of HF patients and therefore, optimization of GDMT needs to be done by general cardiologists and primary care clinicians as well. We should also become creative and use telemedicine to optimize GDMT more efficiently. We do our patients a disservice by not optimizing GDMT that improves HF morbidity and mortality.

And just as optimization of GDMT is not ideal, neither is our evaluation of etiology of HF. Optimization of GDMT and determination of etiology of HF whose management may change disease trajectory should be undertaken in all patients with new-onset HF. This begins with a fundamental understanding of the various etiologies of HF, the laboratory and imaging testing needed, and the best treatment strategy for the underlying etiology discovered- if any (cue, “idiopathic” cardiomyopathy). O’Connor and colleagues’ observational cohort study from the Get With The Guidelines- Heart Failure (GWTG-HF) registry demonstrates the need to improve the testing we perform to exclude coronary artery disease (CAD) as the underlying etiology of new-onset HF.4

Why is this important? Well, of course for treatment, which involves deciding whether medical therapy (aspirin, statins) or revascularization (surgical or percutaneous) is a more optimal strategy. And most important to improve disease trajectory as continued ischemia will lead to worsening HF. O’Connor and colleagues found that the majority of  17,185 patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after, despite data demonstrating that 60% (!!!) of HF patients have concomitant significant CAD.4 And consistent with disparities I mentioned earlier regarding the undertreatment of women with GDMT, men were more likely to be tested for CAD.

Diagnosing and treating CAD provides an opportunity to discuss risk factor modification with patients such as smoking cessation, diabetes control, exercise, healthy diets etc.… to further mitigate future risk. The importance of optimization of GDMT in patients with HFrEF cannot be understated and analogous to this, is the importance of examining the underlying etiology of HF in patients with new-onset HF with preserved, borderline, or reduced EF to improve disease trajectory. Furthermore, inequities in both aspects of the care of HF patients in terms of identification of etiology and optimization of GDMT, must be addressed on a national level. We have plenty of data illustrating suboptimal optimization of GDMT in those with established HFrEF and suboptimal testing for CAD in those with new-onset HF. The next steps are understanding the mechanisms and implementing strategies to improve care. The need for this is critical to reduce morbidity and mortality in all HF patients.

References

  1. Yancy CW, Jessup M, Bozkurt B et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;137.
  2. Yancy CW, Januzzi JL, 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. Journal of the American College of Cardiology 2017.
  3. Greene SJ, Butler J, Albert NM et al. Contemporary Utilization and Dosing of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: From the CHAMP-HF Registry. Journal of the American College of Cardiology 2018.
  4. O’Connor, Kyle D., et al. “Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure.” Circulation: Heart Failure, vol. 13, no. 4, 2020, doi:10.1161/circheartfailure.120.006963.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Heart Failure Management and the Challenge of Systems-Based Practice Implementation for Optimization of Guideline Directed Medical Therapy

As the population continues to age, along with the addition of lifesaving and prolonging medical therapies, the prevalence of HF will continue to increase. In this article, we will solely focus on Heart Failure with Reduced Ejection Fraction (HFrEF), and the potential solutions to the issues with the optimization of guideline directed medical therapy (GDMT) on a systems level.

Robust evidence has established a mortality benefit of GDMT for patients with left ventricular dysfunction. Although the known benefits of GDMT have continued to solidify, there remains a visible gap among patients with HFrEF and the efficacy of treatment.

The issues that exist are likely not based on the individual pharmaceutical therapies profile. Furthermore, medication intolerance and incomplete prescription data can only partially be blamed. Nevertheless, the problems are on a bigger scale, and they involve many different components of our care system.

Let’s discuss some of the barriers to the optimization of GDMT in patients with HFrEF: patient providers and the care system. Providers, including non-cardiologists, should be trained adequately to be able to initiate patients on appropriate medications for HFrEF. They should also know the threshold to discontinue the medications, their side effects, the major contraindications, and, most importantly, when to seek help. HF patients are often complex, and it is essential to know that the different providers involved in their care should be in constant communication when it comes to their medical regimen. It is not enough to start the medication. It’s of utmost importance to continue increasing the dosages as tolerated by the patient to at least the dosages used in the different studies where these medications have shown the most benefits. Education is a key aspect, and it should involve the patient, patient’s family, providers, and everybody in the care system responsible for the patient including nurses and pharmacists. I propose 2 points among many out there:

  1. Standardized education for everybody involved in the patient’s care
  2. Standardized methods of communication between the different providers involved in the patient’s care including the patient and their families.
Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure

Figure 1. Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure1.

The purpose of this article is not to re-invent the wheel. The American Heart Association Heart Failure Summit in 2017 identified opportunities to improve care and outcomes and reduce disparities for patients with HF.(Figure 1). The purpose of this article is to remind us that we should be focusing more on implementation strategies for GDMT. We already have the tools, and, as we speak, we are adding new ones. It’s not just the tools; it is how you make use of them that will be the difference.

In summary, establishing and implementing systems of care that can help increase the number of patients on GDMT with the focus on improving medication adherence will ultimately lead to better outcomes. What is certain is that we must continue to meet the challenges of the realities of GDMT and their barriers. Our patients with heart failure depend on it.

References

  1. Pamela N. Peterson. Circulation: Heart Failure. The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017, Volume: 11, Issue: 10, DOI: (10.1161/CIRCHEARTFAILURE.118.004957)

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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Live Streaming Into Scientific Sessions 2018

AHA Scientific Sessions 2018 was a unique experience for me – unable to attend the meeting, I live-streamed the sessions (first time ever for a conference!). Two of my most favorite sessions this year were the panel discussion for advanced heart failure (HF) patients, “The Metabolic Face of Heart Failure,” and the mini-symposium on “Cutting Edge in Cardiovascular Science.”

One of the main highlights in the session Metabolic Face of HF, moderated by Dr Lynne Stevenson, was the talk by cardiovascular stalwart Dr. E. Braunwald, Brigham and Women’s Hospital. Dr. Braunwald spoke of the significance and latest practices in the use of Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors, a class of FDA-approved drugs for type-2 diabetes. He indicated how SGLT2 inhibitors should be explored beyond diabetes treatment and these class of drugs can benefit HF patients as well. “I had to learn about blood clotting 30 years ago, which was difficult,” he modestly admitted as he clarified the renal effects of SGLT2 inhibition. His views also seemed to resonate with Dr. Subodh Verma, St. Michael’s Hospital, Toronto and Dr. John McMurray, Glasglow University, as they covered SGLT2 inhibitors in HF, as well.

Other speakers at this session, Dr. Neha Pagidipati, Duke University and Dr. Lewandowski, Ohio State University, touched upon aspects of stroke and metabolism regulating HF, respectively. While Dr. Pagidipati compared the risk of cardiovascular diseases and stroke with the risks of diabetes, Dr. Lewandowski explained how metabolic regulator PPAR-a (transcriber of genes in fat metabolism) could be a player explored in targeted therapy.

The session ‘Cutting Edge in Cardiovascular Science’ had presenters covering diverse strategies in dealing with cardiovascular therapy, ranging from computational screening to identifying small molecule compounds, to decoding neurovascular networks and the gut microbiome. Dr. Stanley Hazen from Cleveland Clinic presented his work on understanding the microbes in the gut and their role in driving cardiovascular diseases. Dr. Hazen explained how food like red meat, which are rich in components like phosphatidyl serine, activates the gut microbiome. He described the significance of trimethylamine N-oxide (TMAO) pathway in liver and its association with HF, stroke and cardiovascular diseases. He also strategized the use of enzyme in TMAO pathway as targets of small molecule inhibitors.

Dr. Joseph Loscalzo, Brigham and Women’s Hospital, explained how repurposing drugs and finding drug targets computationally could help precision medicine vastly. He also offered his expertise and tools as open access to AHA members. Finally, Dr. Costantino Iadecola, Cornell, elaborated on the heart-brain connectome. He brought attention to the fact that dementia, known to cause hardening of arteries, led to Alzheimer’s, but we all forgot about the vascular complications of this. He bridged this connection between neurovascular dysfunction and cognitive impairment and went on to explain his research on the intake of high salt in diet caused dementia in mice models. To learn of such versatile range of topics in a session was illuminating, to say the least!

Researchers must spend time thinking about applications of their current projects beyond their own niche – this is the only way we can widen our horizons with existing tools.