Updated guideline redefines HF stages, emphasizes prevention, new treatments
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WASHINGTON — A joint guideline from the American College of Cardiology, the American Heart Association and the Heart Failure Society of America redefines HF stages to focus on prevention and recommends HF treatment with SGLT2 inhibitors.
The new guideline, presented at the American College of Cardiology Scientific Session, is the first full revision since 2013, replacing the ACC Foundation/AHA Guideline for the Management of Heart Failure and the 2017 ACC/AHA/HFSA Focused Update of the 2013 guideline.
The guideline was simultaneously published in the Journal of the American College of Cardiology, Circulation and the Journal of Cardiac Failure.
“We have very important updates to the recommendations, including quadruple classes of medications indicated for patients with HF with reduced ejection fraction,” Biykem Bozkurt, MD, PhD, The Mary and Gordon Cain Chair and Professor of Medicine and director of the Winters Center for Heart Failure Research at Baylor College of Medicine, past president of HFSA and vice chair of the writing committee, told Healio. “These include SGLT2 inhibitors, along with beta-blockers, mineralocorticoid receptor inhibitor antagonists (MRA), renin-angiotensin-aldosterone inhibition with angiontensin receptor neprilysin inhibitors (ARNI), angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers.”
Use of SGLT2 inhibitors
The guideline also includes recommendations for patients with HF with mildly reduced EF, Bozkurt said; a class 2A recommendation for SGLT2 inhibitors and a class 2B recommendation for ARNI, MRA, beta-blockers or angiotensin receptor blockers.
“We also have new recommendations for patients with HF with preserved EF, which also includes a class 2A recommendation with SGLT2 inhibitors also class 2B recommendations for MRAs, ARNI and angiotensin receptor blockers,” Bozkurt said in an interview. “We have a variety of new sections in the guidelines, including cardio-oncology and cardiac amyloidosis. We also have a section for comorbidities including treatment of patients with HF with AF, valvular heart disease, iron deficiency, sleep apnea and diabetes.”
New staging of HF
The guideline updates include a new focus on preventing HF in people who are showing early signs of “pre-heart failure,” with an emphasis on optimizing BP and adherence to a healthy lifestyle. The societies also revised the ACC/AHA stages of HF — from stage A to stage D — to emphasize development and progression of the disease, with advanced stages indicating more serious disease and reduced survival rate.
“The ACC/AHA stages of HF emphasize the development and progression of disease and advanced stages and progression are associated with reduced survival,” the researchers wrote. “Therapeutic interventions in each stage aim to modify risk factors (stage A), treat risk and structural heart disease to prevent HF (stage B), and reduce symptoms, morbidity and mortality (stages C and D).”
Stage A, defined as “at risk but without symptoms,” includes people with hypertension, diabetes, metabolic syndrome and obesity, or exposure to medications or treatments that may damage the heart or hereditary risk factors. The new guidance puts a sizable portion of the U.S. population at risk for HF; approximately 121.5 million people in the U.S. have hypertension, 100 million have obesity and 28 million have diabetes. The guideline recommends clinicians consider SGLT2 inhibitors for people with type 2 diabetes and either established CVD or high CV risk.
New classifications of EF
For people with stage C HF, the new guideline refines the current four classifications of HF based on left ventricular EF with new terminology:
- HFrEF includes people with left ventricular EF of less than 40%.
- HF with improved ejection fraction includes people with previous LVEF of less than 40% and a follow-up measurement of greater than 40%.
- HF with mildly reduced ejection fraction includes people with LVEF of 41% to 49% and evidence of increased LV filling pressures.
- HFpEF includes individuals with LVEF of at least 50% and evidence of increased LV filling pressures.
The guideline also includes recommendations for implantable cardiac devices and cardiac revascularization therapy, diagnosis and treatment of cardiac amyloidosis, specialty referrals for individuals with stage D advanced HF and recommendations for management of AF and valvular heart disease in HF and cardio-oncology.
“We have also added value statements where there were high quality publications for treatments used in HF and we think these will be very helpful for our clinicians,” Bozkurt told Healio. “The figures, tables and recommendations will assist clinicians in implementing the guidelines and helping us advance care for our HF patients.”
References:
- Heidenreich PA, et al. Circulation. 2022;doi:10.1161/CIR.0000000000001063.
- Heidenreich PA, et al. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2021.12.012.
- Heidenreich PA, et al. J Card Fail. 2022;doi:10.1016/j.cardfail.2022.02.010.
Perspective
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Michelle M. Kittleson, MD, PhD
I am very excited about several areas of this guideline. First is the new distinctions in classification of ejection fraction. We have the traditional HFrEF of 40% or less; HFpEF of 50% or higher; and now highlighting an EF between 41% and 49% and an EF that is improving. This reinforces the importance of the patient’s trajectory. Pay attention, is the patient getting better or worse? If they are improving, do not stop the guideline-directed medical therapy.
Second is the inclusion of SGLT2 inhibitors, the latest pillar of guideline-directed medical therapy along with the beta-blockers and MRAs as optimal for patients. The third is inclusion of amyloidosis. In the 2013 guideline, amyloidosis was mentioned twice. Now, there is an entire section devoted to treatment. This reflects the extraordinary advances in our ability to recognize the prevalence and diagnosis of transthyretin amyloidosis noninvasively and having an FDA-approved therapy that reduces hospitalizations and improves survival.
The final piece I want to mention was the addition of the value statements, so we think not just about the benefits of treatments but also the cost and how we balance the two. There is also emphasis on reducing disparities.
This guideline offers not just the best of science but the best way to implement the science as well.
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Heidenreich PA, et al. Party Like It’s 2022: The Latest Guidance in Heart Failure Care. Presented at: American College of Cardiology Scientific Session; April 2-4, 2022; Washington, D.C. (hybrid meeting).
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