ACC expert consensus pathway highlights ‘revolutionary’ advances in HFpEF management
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Key takeaways:
- A new expert consensus decision pathway stresses proper diagnosis and treatment of HF with preserved ejection fraction.
- Managing comorbidities and working with a multidisciplinary team are key.
HF with preserved ejection fraction is a complex condition with multiple overlapping comorbidities that requires timely diagnosis and optimal guideline-based therapies, according to new guidance from the American College of Cardiology.
The ACC published an expert consensus decision pathway outlining best practices for treating and managing HFpEF, which now accounts for more than half of all HF cases. HFpEF has outcomes comparable to HF with reduced EF; however, HFpEF is often underrecognized and results in substantial resource utilization, according to Michelle M. Kittleson, MD, PhD, director of postgraduate medical education in heart failure and transplantation and professor of medicine at the Smidt Heart Institute at Cedars-Sinai.
“The diagnosis of HFpEF is tricky and we now have effective therapies, namely, SGLT2 inhibitors, so it is important to spread the word about diagnosis and treatment,” Kittleson, the chair of the writing committee for the expert consensus decision pathway, told Healio. “HFrEF [diagnosis] is easy in the sense that you can check an echo and then proceed down the treatment pathway. With HFpEF, patients with dyspnea and edema present in so many different ways and may not even present to a cardiologist. The most valuable lesson is if you have a patient with dyspnea and edema, is it truly the heart’s fault? If it is, the next step is to make sure you are not missing disease for which there is disease-directed therapies, particularly something like amyloidosis or hypertrophic cardiomyopathy. If that is not the case, then there is a diagnosis of HFpEF.”
Use a two-pronged approach
Kittleson said a two-pronged approach is needed when caring for patients with HFpEF. The first is the use of optimal guideline-directed medical therapy (GDMT) and the other is managing comorbidities.
“There is an incredible impact and interplay of comorbidities in HFpEF,” Kittleson said. “Comorbidities can lead to HFpEF and treatment of the comorbidities is important, including type 2 diabetes, chronic kidney disease, hypertension, coronary artery disease, obesity and sleep apnea.”
Recent data from two landmark trials demonstrated that benefit of SGLT2 inhibitors in HFpEF. In 2021, the EMPEROR-Preserved trial demonstrated the SGLT2 inhibitor empagliflozin (Jardiance, Boehringer Ingelheim/Eli Lilly) improved clinical outcomes in HFpEF with or without diabetes, reducing the primary outcome of CV death or HF hospitalization by 21% compared with placebo. In August 2022, data from DELIVER showed the SGLT2 inhibitor dapagliflozin (Farxiga, AstraZeneca) similarly reduced risk for CV death and worsening HF compared with placebo in adults with HF with mildly reduced or preserved EF, with no attenuation of treatment benefit for patients with the highest EF.
“After the SGLT2 inhibitor, think about what other agents you might use on an individualized basis,” Kittleson said. A treatment algorithm for GDMT in HFpEF in the pathway document outlines the use of loop diuretic agents, mineralocorticoid receptor antagonists, an angiotensin receptor/neprilysin inhibitor or an angiotensin receptor blocker.
The document also highlights the benefits of lifestyle changes, in particular physical activity, Kittleson said.
“Historically, treatment options were limited to managing comorbidities; however, revolutionary advances in the past decade regarding the pathophysiology of HFpEF, improved methods of diagnosis, and insights into prognostic predictions now yield novel, effective management strategies,” the researchers wrote. “With recent favorable clinical trial results, there is increasing urgency for accurate diagnosis and timely implementation of GDMT.”
The decision pathway addresses several pivotal issues related to HFpEF, including:
- how to approach a person with shortness of breath;
- how to overcome diagnostic dilemma and identify a need for further testing;
- how to rule out mimics to avoid missed diagnosis;
- how to manage comorbidities and address complexities in care;
- how to initiate and optimize GDMT;
- when and why to refer to a cardiologist or HF specialist;
- how to improve access to care; and
- how to recognize sex-specific differences in diagnosis and care management.
In an accompanying JACC scientific statement, the JACC Editorial Board and ACC Heart Failure and Transplant Section provided an in-depth analysis of the current epidemiology, pathophysiology, diagnosis and treatment of HFpEF. The scientific statement also addresses knowledge gaps in care and future therapeutic strategies.
Kittleson said it is also crucial that clinicians know when to refer a patient with HFpEF for more specialized care. The decision pathway includes two acronyms, CHECK-IN and INHALE, that outline when a primary care physician should refer a patient to a cardiovascular specialist and when a cardiologist should refer a patient on to a HF specialist.
“Medicine is a team sport; you cannot know everything,” Kittleson said. “The key is to collaborate effectively. If you are unsure about the diagnosis or, despite interventions, the patient is worsening, you need to reach out and collaborate.”
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For more information:
Michelle M. Kittleson, MD, PhD, can be reached at michelle.kittleson@cshs.org; Twitter: @mkittlesonmd.
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