Societies Release Focused Update For HF Management

Recommendations on two new heart failure (HF) medications are detailed in a focused update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure, released May 20 by the ACC, American Heart Association (AHA) and Heart Failure Society of America and published in the Journal of the American College of Cardiology.

The focused update includes the addition of an angiotensin receptor-neprilysin inhibitor (ARNI) (valsartan/sacubitril), and a sinoatrial node modulator (ivabradine) to the list of treatment options for Stage C HF patients with a reduced ejection fraction. The previously determined drug options for these patients include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), aldosterone antagonists, beta blockers, the combination of isosorbide dinitrate and hydralazine and diuretics.

Of note, the writing committee recommends a therapeutic regimen of an ACE inhibitor or ARB or ARNI along with a beta blocker and an aldosterone antagonist for patients with chronic symptomatic HF with reduced ejection fraction. ARNIs should replace ACE inhibitors (or ARBs) when stable patients with mild-to-moderate HF on these therapies have an adequate blood pressure and are otherwise tolerating standard therapies well. ARNIs, however, should not be used with an ACE inhibitor and should not be used by patients with a history of angioedema.

In addition, ivabradine may be beneficial in reducing HF hospitalizations in patients with symptomatic stable chronic HF with reduced ejection fraction who are receiving guideline-directed evaluation and management, including a beta blocker at a maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 beats per minute or greater at rest.

“Not every patient is a good candidate for every drug; these guidelines can help physicians decide who best fits which treatment,” explains Clyde W. Yancy, MD, MSc, MACC, chair of the writing committee. “This document details the benefits and risks of these new therapies so that patients at high risk can be directed towards alternative therapies.”

While a full update to the guideline is currently being developed, these recommendations were released early to coincide with the publication of similar recommendations from the European Society of Cardiology (ESC).

In an editorial released with the focused update, Elliott M. Antman, MD, MACC, et al., write that “The officers of the ACC, AHA, and ESC and their respective guideline oversight committees meet regularly to discuss opportunities for coordination and alignment on overlapping topics and evolution of the methodology used to gather and evaluate scientific evidence. The objective is to promote optimal care for patients with all forms of cardiovascular disease to improve outcomes and enhance quality of life around the world. The new documents represent an important step in this direction.”

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