2021 Expert Decision Pathway for HFrEF Treatment Optimization

Maddox TM, Januzzi JL Jr, 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: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021;Jan 11:[Epub ahead of print].

The following are key points to remember from the 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment:

  1. For patients with newly diagnosed Stage C heart failure with reduced ejection fraction (HFrEF), a beta-blocker and an angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI) should be started in any order. Each agent should be up-titrated to maximally tolerated or target dose. Initiation of a beta-blocker is better tolerated when patients are dry and an ACEI/ARB/ARNI when patients are wet.
  2. Only guideline-recommended beta-blockers (i.e., carvedilol, metoprolol succinate, or bisoprolol) should be used in patients with HFrEF. Among angiotensin antagonists, ARNIs are preferred agents. Renal function and potassium should be checked within 1-2 weeks of initiation or dose up-titration of ACEI/ARB/ARNI.
  3. Diuretics should be added as needed and dose should be titrated to achieve decongestion. If doses in excess of furosemide 80 mg twice daily are needed, either a different loop diuretic should be considered or a thiazide should be added.
  4. After initiation of beta-blocker and angiotensin antagonist, addition of an aldosterone antagonist should be considered with close monitoring of electrolytes. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors should also be considered for HFrEF with New York Heart Association (NYHA) class II-IV patients.
  5. For persistently symptomatic Black patients despite above therapies, hydralazine and isosorbide dinitrate should be considered. In addition, if despite maximally tolerated beta-blocker, resting HR is ≥70 bpm in sinus rhythm, ivabradine may be considered.
  6. An ideal time to consider therapy optimization is during hospitalization for HFrEF. As an outpatient, adjustment of therapies should be considered every 2 weeks to achieve guideline-directed medical therapy (GDMT) within 3-6 months of initial diagnosis. An echocardiogram should be repeated 3-6 months after achieving target doses of therapy for consideration of an implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy (CRT).
  7. Surgical treatment is recommended for patients with severe primary chronic mitral regurgitation. For severe chronic functional mitral regurgitation, optimization of GDMT is recommended prior to consideration of percutaneous transcatheter repair in symptomatic patients only.
  8. Hyperkalemia and/or abnormal renal function are common barriers to achieving target medication doses. Patients with hyperkalemia should be educated about a low potassium diet. Potassium binders may be considered.
  9. Socioeconomic barriers pose a major barrier to use of ARNI, SGLT-2 inhibitors, and ivabradine. In these cases, financially feasible options should be considered. This may include virtual care and visiting home nursing services particularly during the coronavirus disease 2019 (COVID-19) pandemic.
  10. For patients with recovery of left ventricular ejection fraction (LVEF) to >40%, GDMT should be resumed in the absence of a defined, reversible cause.
  11. Repeat echocardiograms should be considered in the context of change in clinical status or other high-risk features only. Measuring B-type natriuretic peptide (BNP) or N-terminal–proBNP (NT-proBNP) is useful for risk assessment and decision making regarding referral to a HF specialist or assessing need for other imaging studies. BNP levels may rise with use of ARNI therapy, but NT-proBNP levels are not impacted.
  12. Right heart catheterizations should be considered when symptoms persist despite adequate diuretic dose, worsening renal function with attempts to use higher dose therapies including diuretics or those with repeated hospitalizations for decompensation. In highly selected patients with recurrent congestion, an implantable sensor to guide filling pressure assessment (e.g., CardioMEMS) in ambulatory HF patients may be considered.
  13. Referral to a HF specialist should be considered in patients needing inotropes, NYHA class IIIB/IV symptoms or persistently elevated natriuretic peptides, end-organ dysfunction, EF ≤35%, ICD shocks, recurrent hospitalizations, congestion despite escalating diuretics, low blood pressure and/or high heart rate, and progressive intolerance to GDMT needing down-titration.
  14. Delivering care for HF requires a team-based approach. Infrastructure such as provision of patient monitoring devices (e.g., Scales) or smartphones or electronic health records can support such team-based care.
  15. Medication adherence should be assessed regularly. Interventions helping with adherence include patient education, medication management, pharmacist co-management, cognitive behavioral therapies, medication taking reminders, and incentives to improve adherence.
  16. Goals of care should be addressed during the course of illness with HF and expectations should be calibrated to guide timely decisions. When feasible, decision support tools should be used. End-of-life care in HF involves meticulous management of HF therapies, and palliative care consultation may help with other noncardiac symptoms such as pain.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Biomarkers, Cardiac Catheterization, Comorbidity, Costs and Cost Analysis, Defibrillators, Implantable, Delivery of Health Care, Integrated, Delivery of Health Care, Diagnostic Imaging, Diuretics, Drug Therapy, Echocardiography, Geriatrics, Guideline, Heart Failure, Hemodynamics, Hospices, Hyperkalemia, Medication Adherence, Mitral Valve Insufficiency, Organization and Administration, Palliative Care, Patient Compliance, Pharmacology, Referral and Consultation, Stroke Volume, Therapeutics

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