Summary of New American Recommendations for Heart Failure Management
This year, the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA) released joint recommendations for the diagnosis and treatment of heart failure in clinical practice. These new guidelines replace the previous recommendations from 2013 and their 2017 update. We summarize the 10 key points to remember as outlined by the authors of the new guidelines and focus on the treatment of the subgroup of patients with heart failure with preserved ejection fraction (HFpEF).
Points to Remember
- Recommended treatment for heart failure with reduced ejection fraction (HFrEF) includes 4 classes of drugs: sodium-glucose cotransporter 2 inhibitors (SGLT2i, gliflozins), angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II type 1 receptor blockers (ARBs, sartans) for NYHA II–IV, angiotensin II type 1 receptor and neprilysin inhibitors (ARNI) for NYHA II–III, mineralocorticoid receptor antagonists (MRA), and beta-blockers (BB).
- For patients with heart failure with mildly reduced ejection fraction (HEmrEF), SGLT2i have a class 2a recommendation, while ARNI, ACEi, ARBs, MRA, and BB have a weaker class 2b recommendation.
- New recommendations for HFpEF related to SGLT2i (class 2a), MRA, and ARNI (class 2b) have been included. Recommendations for the treatment of hypertension, atrial fibrillation, and the use of ARBs have been revised, and the routine use of nitrates or phosphodiesterase 5 inhibitors (PDE5i) has been omitted.
- Patients with HFrEF, who have shown improvement in left ventricular ejection fraction (LVEF) to > 0.4, are now referred to as patients with improved LVEF. Continued HFrEF treatment is recommended for them.
- For selected recommendations, where high-quality cost-effectiveness studies are available, statements on costs have been added.
- New recommendations for the diagnosis and treatment of cardiac amyloidosis have been developed. These include screening for monoclonal light chains in serum and urine, bone scintigraphy, DNA sequencing, treatment with transthyretin tetramer stabilizers, and anticoagulation therapy.
- If LVEF is > 0.4, evidence of increased filling pressures, based on non-invasive methods (e.g., natriuretic peptides, diastolic function by imaging) or invasive methods (e.g., hemodynamic measurements), is critical for the diagnosis of heart failure.
- Patients with advanced heart failure who wish to prolong survival should be referred to a specialized heart failure team. This team will review current heart failure treatment and assess appropriate advanced treatment and palliative care, in line with the patient's care goals and wishes.
- Stages of heart failure have been revised with new terms: “at risk for heart failure” for stage A and “pre-heart failure” for stage B.
- Specific recommendations have been included for patients with heart failure and iron deficiency, anemia, hypertension, sleep disturbances, type 2 diabetes, atrial fibrillation, ischemic heart disease (IHD), and cancer.
Synopsis of Recommendations for Patients with HFpEF
HFpEF with LVEF ≥ 0.5 affects up to 50% of heart failure patients. Besides its high prevalence, it is associated with significant morbidity and mortality. It is a heterogeneous disease influenced by the presence of hypertension, diabetes, obesity, IHD, chronic kidney disease, and in specific cases, cardiac amyloidosis. Clinical trials have used various definitions of HFpEF: LVEF ≥ 0.4, ≥ 0.45, ≥ 0.50, along with the need for evidence of structural heart damage or elevation in natriuretic peptides.
To date, clinical trials have not provided evidence of the benefit of treatment in terms of mortality and only marginal evidence of reduced risk of heart failure hospitalizations. Newly, it is recommended to adhere to the general guidelines for heart failure treatment, including the use of diuretics to reduce congestion and alleviate symptoms. Treatment must also involve identifying and addressing specific causes, such as cardiac amyloidosis, and the management of comorbidities, such as hypertension, IHD, and atrial fibrillation.
Current recommendations are as follows:
- For patients with HFpEF and hypertension, medication should be titrated to achieve target blood pressure values in line with current standards for hypertension treatment, aiming to prevent morbidity (class 1 recommendation).
- The use of SGLT2i may reduce the risk of heart failure hospitalizations and cardiovascular mortality in patients with HFpEF (class 2a recommendation).
- Treating atrial fibrillation in these patients may alleviate symptoms (class 2a recommendation).
- In selected patients with HFpEF, particularly at the lower end of the LVEF spectrum, consideration may be given to using MRA, ARBs, or ARNI to reduce the risk of hospitalization (class 2b recommendation for all drug groups).
- The routine use of nitrates or PDE5i to increase activity or quality of life is ineffective and not recommended.
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Source: Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA guideline for the management of heart failure. J Card Fail 2022 May; 28 (5): e1−e167, doi: 10.1016/j.cardfail.2022.02.010.
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