Expert Consensus on Optimization of Heart Failure Treatment

Yancy CW, Januzzi JL Jr, 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. J Am Coll Cardiol 2017;Dec 22:[Epub ahead of print].

The following are key points to remember from this American College of Cardiology (ACC) Expert Consensus Decision Pathway for Optimization of Heart Failure (HF) Treatment, which addresses 10 pivotal issues about HF with reduced ejection fraction (HFrEF):

  1. Initiate and Switch: Initiate angiotensin-converting enzyme inhibitors (ACEI)/angiotensin-receptor blockers (ARBs), beta-blockers, and diuretics. When stable on ACEI/ARBs, switch to angiotensin receptor-neprilysin inhibitors (ARNI) in those with stable blood pressure (BP) and estimated glomerular filtration rate >30 ml/min/1.73 m2 (ensure off ACEI for 36 hours). Add aldosterone antagonist, ivabradine, or hydralazine/isosorbide dinitrate (HYD-ISDN; in African Americans) if no contraindications.
  2. Titrate: Titrate diuretic dose over days to weeks to release congestion, consider increasing dose of ACEI/ARB/ARNI/aldosterone antagonist/HYD-ISDN every 2 weeks until maximum tolerated or target dose.
  3. Referral to HF Specialist: Uses the acronym I-NEED-HELP.
    • I: Intravenous inotropes
    • N: New York Heart Association (NYHA) class IIIB/IV or persistently elevated natriuretic peptides
    • E: End-organ dysfunction
    • E: EF ≤35%
    • D: Defibrillator shocks
    • H: Hospitalizations >1
    • E: Edema despite escalating diuretics
    • L: Low systolic BP ≤90, high heart rate
    • P: Prognostic medication; progressive intolerance or down-titration of guideline-directed medical therapy [GDMT])
  4. Care Coordination:
    • More than 50% of the HF Medicare patients have four or more noncardiovascular comorbidities and more than 25% have six or more—raising the risk of inefficiencies of care delivery, miscommunication, potential drug-drug interactions and drug-disease interactions, and missed opportunities to achieve optimal outcomes.
    • Team-based care is probably the most effective approach; team-based care by definition is “delivery of health services to individuals, families, and/or their communities by at least two health care providers who work collaboratively with patients and their caregivers, in concordance with patient preference, to achieve shared goals within and across settings.”
  5. Adherence: Improving adherence involves:
    • Understanding reasons for nonadherence including patient factors (such as poor health literacy, perceived lack of effect, depression, social isolation, cognitive and physical impairment), medical condition (polypharmacy due to multiple comorbidities), therapy (frequency of dosing, side effects), socioeconomics (out-of-pocket cost, difficult access to pharmacy), and health system (poor communication, silos of care, no automatic refills).
    • Shifting the language from patient ‘compliance’ to ‘adherence’ and now to ‘activation,’ ‘engagement,’ and ‘empowerment.’ Patients need support; blame is counterproductive.
    • Capitalizing on opportunities to improve adherence (such as pre-discharge initiation of GDMT), simplifying medication regimens, communicating with other clinicians involved in care, consideration of costs and access, recommending tools that support adherence in real-time (such as pillboxes filed by caregivers), anticipating problems (such as refills), considering behavioral supports (such as motivational interviewing), and monitoring adherence in those at risk (carrying out medicine reconciliation, assessing remaining dosage units, monitoring pharmacy fills, reviewing drug levels such as digoxin, international normalized ratio [INR], monitoring N-terminal pro-B-type natriuretic peptide [NT-proBNP]/BNP, and home-based nursing visits).
    • Specific patient interventions including medication education, disease education, teaching of self-monitoring and self-management, and use of mobile health (reminders, warnings, and adherence tracking).
  6. Specific Patient Cohorts: Tailor therapy for African Americans, the frail, and the elderly.
    • African Americans: The risk of angioedema with ACEI and ARNI is high—0.5% with ACEI and 2.4% with ARNI; however, this should not preclude initiation of these agents absent a documented history of angioedema. Also, there are no data for efficacy for ARNI and ivabradine in this population. Consider HYD/ISDN in patients with low systolic BP, rather than ARNI—this expert consensus document recommends shared decision making with the patient.
    • Elderly: The upper range for clinical trials with GDMT has been 75 ± 5 years and there are no data for drugs or devices in patients >80 years of age. There is a higher risk of adverse events, and optimal doses in such patients may be less than maximum tolerated dose in younger individuals. Risks include falls, worsening renal function, polypharmacy, costs, and comorbidity.
    • Frailty: At least 20% of those over age of 80 years are frail. The response to GDMT is uncertain and the ability to impact overall natural history is unclear.
  7. Cost of care: The cost of cardiovascular medications is the second most important for patients with HF (after hospital costs), accounting for 15.6% of direct costs.
    • Strategies for Managing Costs of HF: Coordinate care including labs and imaging results among clinicians, consider limitations of medical coverage, using generic equivalents of GDMT, split tablets (without reducing dose) when appropriate, work with pharmacists to help patients navigate Patient Assistance Programs, and request price matching if a drug is found at a lower cost at another pharmacy.
  8. Managing Increasing Complexity of HF: Ten guiding pathways include:
    • Target doses associated with best outcomes,
    • Assign top priority to addressing factors that limit GDMT (such as worsening azotemia, hyperkalemia, hypotension),
    • Optimal sympathetic nervous system modulation (use target doses of beta-blockers and lower doses of renin-angiotensin-aldosterone system blockade when limited by hypotension),
    • Optimize beta-blocker dose before considering ivabradine,
    • Add HYD-ISDN in NYHA class III/IV African-American patients on optimal doses of other therapy,
    • Consider device therapy (implantable cardioverter-defibrillator and cardiac resynchronization therapy) after optimal doses of medications for 3-6 months,
    • Symptomatic congestion should be treated with diuretics irrespective of other therapies,
    • Optimize team-based care (with electrophysiology experts, nurses, pharmacists, nephrologists, etc.),
    • Tolerability and side effects can be minimized by ‘start low and go slow’ with up-titration, and
    • Focus on the patient’s symptoms and functional capacity as well as improving cardiac function.
  9. Managing Comorbidities: There is a bidirectional relationship between HF comorbidities whereby the presence of one increases the severity of the other. And the prognosis is worse when both are present. Important cardiovascular morbidities with associations in parentheses include: coronary artery disease (strong), atrial fibrillation/flutter (strong), mitral regurgitation (strong), aortic stenosis (strong), hypertension (uncertain), dyslipidemia (uncertain), peripheral vascular disease (moderate), and cerebrovascular disease (moderate). Noncardiovascular comorbidities include obesity (moderate inverse association), chronic lung disease (strong), diabetes mellitus (strong), chronic renal disease (strong), anemia (moderate), iron deficiency (strong), hypo- or hyper-thyroid disorder (strong), and sleep-disordered breathing. Although targeting comorbidities does not uniformly improve HF outcomes, it is important to do so to improve OVERALL patient outcomes.
  10. Palliative/Hospice Care: Important points to consider regarding palliative care and transition to hospice include:
    • Soliciting goals of care and focusing on quality of life throughout the clinical course of HF is important.
    • Meticulous management of HF, particularly diuretic therapy, is a critical component of symptom relief and should continue through end of life.
    • Palliative care consultation can be helpful in ameliorating refractory symptoms such as fatigue, dyspnea, pain, and in managing complex decisions.
    • Patient decision aids and decision support tools help patients to frame options, and these should be followed up with dynamic and personalized conversations.
    • Preparedness-planning discussions should occur annually to review current therapies, and for clarification of patient values and beliefs, anticipation of treatment decisions, and advanced care directives. Similar preparedness-planning discussions should occur at time of major interventions such as left ventricular assist devices and heart transplantations.
    • Attention to clinical trajectory, particularly milestone event recurrent hospitalizations and intolerance to medications due to hypotension or kidney dysfunction, should trigger heightened preparation with patients and families, but without specific estimates of how much time is remaining due to high levels of unpredictability in the clinical course of HF.
    • The transition from ‘do everything’ to ‘comfort only/hospice’ is often bridged by a period of survival, which involves revising GDMT (such as deactivating defibrillator therapy) and addition of therapies usually not recommended (e.g., opioids for refractory dyspnea).

Keywords: Patient Compliance, Biomarkers, Delivery of Health Care, Delivery of Health Care, Integrated, Comorbidity, Heart Failure, Heart Failure, Systolic, Costs and Cost Analysis, Echocardiography, Geriatrics, Frail Elderly, Functional Residual Capacity, Guideline, Palliative Care, Hospices, Referral and Consultation, Patient Care Team, Blood Pressure, Angiotensin-Converting Enzyme Inhibitors, Adrenergic beta-Antagonists, Diuretics, Dyspnea, Quality of Life

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