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Guideline for the management of heart failure: early prevention for patients at risk, quadruple therapy for those with symptoms
Clinical Question
What are the current treatment recommendations for patients with asymptomatic or symptomatic heart failure?
Bottom line
There is a lot to unpack in this guideline, which is an update from the guideline published by the same group in 2013. Based on studies showing decreased mortality, cardiovascular mortality, or hospitalization, the group recommends starting treatment of asymptomatic patients with an ejection fraction of 40% or less with an ACEi and a beta-blocker. Four-drug therapy is the rule for those with symptomatic heart failure, plus a diuretic to control symptoms. SGLT2 inhibitors feature prominently in the guideline for patients with and without type 2 diabetes, as does the combination of angiotensin receptor-neprilysin inhibitors (the only one currently available is sacubitril/valsartan [Entresto]). 5
Reference
Study design: Practice guideline
Funding: Foundation
Setting: Various (guideline)
Synopsis
This guideline weighs in at 167 pages; fortunately, there is a shorter executive summary that lays out 10 take-home messages. The group now recognizes 4 stages of heart failure: at-risk for heart failure (patients with chronic disease or genetic predisposition that often leads to heart failure), pre-heart failure (based on early signs without symptoms), symptomatic heart failure, and advanced heart failure. Primary prevention in patients at risk should include hypertension control and a sodium glucose cotransporter 2 inhibitor (SGLT2i) in patients with type 2 diabetes. Asymptomatic patients with a reduced ejection fraction (40% or less) should receive treatment with an angiotensin-converting enzyme inhibitor (ACEi) and a beta-blocker. Based on strong evidence, the group recommends quadruple therapy with sacubitril/valsartan, spironolactone or eplerenone, a beta-blocker, and an SGLT2i (regardless of diabetes status) as first-line treatment for all patients with symptomatic heart failure to reduce mortality and hospitalizations, with a diuretic added to control symptoms. The guidelines focus on patient outcomes and are based on a systematic review of the literature. The writing group comprised cardiologists, clinicians from nursing and pharmacy, and lay representatives, and the evidence review was conducted by a methodologist. Many members of the writing group have consulting relationships with the pharmaceutical industry, but the Chair does not.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Relevance
This is a great Poem.
More like this please
distribution of resources, rationing
These recommendations may be biased in favour of the drug companies' interests. Even if they are not, however, they represent a further step towards improved outcomes defined as (marginally) longer life with (marginally) less suffering associated with heart failure. Well and good. But there are more issues individually, locally and globally which trump, I believe, the need to put more resources into this area at this time. We have entered an era (individually, locally, and globally), I believe, of rationing and redistribution of resources, including health care and research. Let the medical advances continue for the sake of science, but let's put public money into the areas that need it most, for the sake of humanity.
Treatment CHF
It is funny how beta blockers were contraindicated in CHF when I first stated my career in medicine. How things change!
Management of Heart Failure
Working group membership industry sponsored
Treating symptomatic potential risk group
Study has clearly emphasized the need to pay attention to symptomatic group with LV EF 40% or less and following the other protocols of the remaining 3stages of pump failure
succint info
to the point
MORE AGGRESSIVE MEDICAL THERAPY FOR CHF
START THERAPY WHEN EF< 40% WITH 4 DRUGS