In HF, assess phenotype, treatment response for individualized care
BOSTON — Optimizing HF therapy is the best way to reduce disease morbidity and mortality and clinicians should consider personalizing and titrating guideline-directed medical therapy based on patient comorbidities, according to a speaker.
“The guidelines for treatment of HF with mildly reduced ejection fraction and HF with preserved EF are quite new, and may still be surprising to some clinicians,” Alanna A. Morris, MD, MSc, FHFSA, FACC, FAHA, director of heart failure research at the Emory Cardiovascular Clinical Research Institute and associate professor of medicine in the division of cardiology at Emory University School of Medicine, told Healio. “For many years, most of the therapies for HF have been targeted at patients with HF with reduced EF; however, it is important to treat all patients with HF, because they are all at high risk for adverse outcomes. It is critical that clinicians understand the treatment guidelines across the spectrum of EF categories.”
Guideline-directed therapy use low
Today, the proportion of patients with HF who are receiving guideline-directed medical therapy remains low and strategies to improve the use of these therapies are urgently needed, Morris said during a presentation at the Cardiometabolic Health Congress.
“Sometimes in the advanced HF clinic, all I do for patients is put them on an [mineralocorticoid receptor antagonist], adjust the diuretic therapy and [the patient] thinks I am a savior,” Morris said. “When, in fact, many of these patients never need to go through transplant or [left ventricular assist device]. It is just simple tweaks to their basic medical therapy, and they feel so much better when you decongest them and give them therapies that will help them.”
An updated, joint guideline from the American College of Cardiology, the American Heart Association and the Heart Failure Society of America published in April redefined HF stages to focus on prevention of HF and recommends HF treatment with novel therapies including SGLT2 inhibitors and angiotensin receptor neprilysin inhibitors (ARNIs), Morris said. The new guideline is the first full revision since 2013.
Morris highlighted the differences in the recommended treatment regimens for HFrEF, HF with mildly reduced EF and HFpEF.
The guideline now emphasizes a four-drug regimen for adults with HFrEF, including SGLT2 inhibitors, along with beta-blockers, mineralocorticoid receptor inhibitor antagonists (MRAs), renin-angiotensin-aldosterone inhibition with ARNIs (preferred), ACE inhibitors and angiotensin receptor blockers.
The guideline also includes recommendations for patients with HF with mildly reduced EF, Morris said; a class 2A recommendation for SGLT2 inhibitors and a class 2B recommendation for ARNIs, angiotensin receptor blockers or ACE inhibitors, and MRAs and beta-blockers.
There are also new recommendations for patients with HF with preserved EF, which also includes a class 2A recommendation for SGLT2 inhibitors and class 2B recommendations for MRAs, ARNIs and angiotensin receptor blockers, she said.
Patients who have improved their LVEF in response to medical therapy for HFrEF where the EF is greater than 40% should continue their HFrEF treatment, Morris said.
“Do not stop their therapy,” Morris said. “We have seen many of these patients come in [with] cardiogenic shock because a clinician or patient decided to stop their therapy because they thought they were cured, because their EF is 55%. We now have randomized data to show that if you withdraw therapy for patients who normalize their EF and their natriuretic peptides, almost 50% of those patients will have a recurrence of HF within 6 months.
“We need to tell patients that their HF is in remission, not cured, keep them on therapy and explain why that is so important,” Morris said.
Patients with advanced HF who have recurrent hospitalizations and wish to prolong their survival should be referred to a team that specializes in HF, including palliative care, consistent with the patient’s goals of care, Morris said.
Titrating therapy: ‘We want to do this rapidly’
Guideline-directed medical therapy for HF should be initiated and titrated rapidly, with clinicians conducting serial reassessment and optimizing dosing, adherence and patient education to address the goals of care, Morris said.
Clinicians should consider specific patient scenarios, such as NYHA class, race and comorbidities, and implement additional guideline-directed medical therapy and device therapy as needed, all while reassessing symptoms, labs, health status and LVEF. Ideally, medical therapy should be titrated and optimized every 1 to 2 weeks, Morris said.
“We do not want to uptitrate the doses to those used in randomized trials at the expense of having patients on all four drugs,” Morris said. “At the beginning, you put them on a low-dose beta-blocker; a low-dose SGLT2 inhibitor, and then you bring them back in 1 to 2 weeks and start the MRA, and then you bring them back in 2 weeks and you start the ARNI. Then, you can uptitrate to the doses based on the patient’s BP and other factors. This is a great place where telemedicine can be useful. We want to do this rapidly.”
‘We have a lot to offer these patients’
The updated guideline notes that a timely referral for patients with signs and symptoms of advanced HF is key, Morris said. It is important to assess patients for clinical clues that they may have advanced HF; these include persistent NYHA class III to IV symptoms, at least two ED visits or hospitalizations for HF in 12 months, a high-risk biomarker profile and an inability to uptitrate guideline-directed medical therapies because of hypotension, dizziness or worsening renal function. Other signs include an onset or worsening of atrial or ventricular arrhythmias like atrial fibrillation, escalating doses of diuretics or persistent edema despite escalating diuretic doses and a need for IV inotropes.
“We often see this referral happen too late, when a patient has irreversible multiorgan system dysfunction and we are talking about a heart transplant or a multiorgan transplant,” Morris said. “We want to refer these patients while still in the ‘golden window.’ … We have a lot to offer these patients, we just need to get them there.”
The landscape of medical therapies for the treatment of HFrEF, HF with mildly reduced EF and HFpEF continues to rapidly evolve, and options can be confusing for clinicians, so it is crucial to refer back to the updated HF guidelines, Morris said.
“Of course, for those patients who are not tolerating drugs, make sure they are referred to an advanced HF center where we can offer them something more than just medical therapy,” Morris said.
Reference:
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Morris AA. Challenges and advances in heart failure management: How to individualize therapy accordingly. Presented at: Cardiometabolic Health Congress; Oct. 19-22, 2022; Boston.