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HF TTT

Treatment of HF

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wadabu19811979
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13 views4 pages

HF TTT

Treatment of HF

Uploaded by

wadabu19811979
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Phar­ma­cother­a­py is the cor­ner­stone of treat­ment for HFrEF and should be im­ple­ment­ed be­fore con­sid­er­ing de­vice ther­a­py,

and along­side non-​phar­ma­co­log­i­cal in­ter­ven­tions.

There are three ma­jor goals of treat­ment for pa­tients with HFrEF: 1) re­duc­tion in mor­tal­i­ty, 2) pre­ven­tion of re­cur­rent hos­pi­‐
tal­iza­tions due to wors­en­ing HF, and 3) im­prove­ment in clin­i­cal sta­tus, func­tion­al ca­pac­i­ty and qual­i­ty of life (QOL).

Mod­ul­a­tion of the renin-​an­giotensin-​al­dos­terone (RAAS) and sym­pa­thet­ic ner­vous sys­tems (SNS) with an­giotensin-​con­vert­‐
ing en­zyme in­hibitors (ACE-​I) or an an­giotensin re­cep­tor-​neprilysin in­hibitor (ARNI), beta-​block­ers, and min­er­alo­cor­ti­coid re­‐
cep­tor an­tag­on ­ ists (MRA) has been shown to im­prove sur­vival, re­duce the risk of HF hos­pi­tal­iza­tions and re­duce symp­toms,
in pa­tients with HFrEF. These drugs serve as the foun­da­tions of phar­ma­cother­a­py for pa­tients with HFrEF. The tri­ad of an
ACE-​I/​ARNI, a beta-​block­er and an MRA is rec­om­mend­ed as cor­ner­stone ther­a­py for these pa­tients, un­less the drugs are
con­traindi­cat­ed or not tol­er­at­ed. They should be up­ti­trat­ed to the dos­es used in the clin­i­cal tri­als (or to max­i­mal­ly tol­er­at­ed
dos­es if that is not pos­si­ble). This guide­line still rec­om­mends the use of ARNI as a re­place­ment for ACE-​I in suit­able pa­‐
tients who re­main symp­to­matic on ACE-​I, beta-​block­er and MRA ther­a­pies, how­ev­er, an ARNI may be con­sid­ered as a first-​
line ther­a­py in­stead of an ACE-​I.

The SGLT2 in­hibitors da­pagliflozin and em­pagliflozin, added to ther­a­py with ACE-​I/​ARNI/​beta-​block­er/​MRA re­duced the risk
of CV death and wors­en­ing HF in pa­tients with HFrEF. Un­less con­traindi­cat­ed or not tol­er­at­ed, da­pagliflozin or em­pagliflozin
are rec­om­mend­ed for all pa­tients with HFrEF al­ready treat­ed with an ACE-​I/​ARNI, a beta-​block­er and an MRA, re­gard­less of
whether they have di­a­betes or not.

Fig­ure 2 de­picts the al­go­rithm for the treat­ment strat­eg ­ y, in­clud­ing drugs and de­vices in pa­tients with HFrEF, for Class I in­di­‐
ca­tions for the re­duc­tion of mor­tal­i­ty (ei­ther all cause or CV). The rec­om­men­da­tions for each treat­ment are sum­ma­rized be­‐
low.

Fig­ure 2 Ther­a­peu­tic al­go­rithm of Class I Ther­a­py In­di­ca­tions for a pa­tient with heart fail­ure with re­duced ejec­tion frac­tion
ACE-​I = angiotensin-converting enzyme inhibitor; ARNI = angiotensin receptor-neprilysin inhibitor; CRT-D = cardiac resynchronization
therapy with defibrillator; CRT-P = cardiac resynchronization therapy pacemaker; ICD = implantable cardioverter-defibrillator; HFrEF =
heart failure with reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; QRS = Q, R, and S waves of an ECG; SR =
sinus rhythm.
a
As a re­place­ment for ACE-​I.
b
Where appropriate.

Class I=green. Class IIa=Yellow.

For interactivity see here

Phar­ma­co­log­i­cal treat­ments in­di­cat­ed in pa­tients with (NYHA class II-​IV) heart fail­ure with re­duced ejec­tion frac­tion (LVEF
≤40%)

Rec­om­men­da­tions Classa Lev­elb

An ACE-​I is rec­om­mend­ed for pa­tients with HFrEF to re­duce the risk


I A
of HF hos­pi­tal­iza­tion and death.

A beta-​block­er is rec­om­mend­ed for pa­tients with sta­ble HFrEF to re­‐


I A
duce the risk of HF hos­pi­tal­iza­tion and death.

An MRA is rec­om­mend­ed for pa­tients with HFrEF to re­duce the risk


I A
of HF hos­pi­tal­iza­tion and death.

Da­pagliflozin or em­pagliflozin are rec­om­mend­ed for pa­tients with


I A
HFrEF to re­duce the risk of HF hos­pi­tal­iza­tion and death.

Sacu­bi­tril/​val­sar­tan is rec­om­mend­ed as a re­place­ment for an ACE-​I


in pa­tients with HFrEF to re­duce the risk of HF hos­pi­tal­iza­tion and I B
death.

ACE-I = angiotensin-converting enzyme inhibitor; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left
ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NYHA = New York Heart Association. aClass of
recommendation. bLevel of evidence.

Oth­er phar­ma­co­log­i­cal treat­ments in­di­cat­ed in se­lect­ed pa­tients with NYHA class II-​IV heart fail­ure with re­duced ejec­tion
frac­tion (LVEF ≤40%)

Rec­om­men­da­tions Classa Lev­elb

Loop di­uret­ics

Di­uret­ics are rec­om­mend­ed in pa­tients with HFrEF with signs and/​or


symp­toms of con­ges­tion to al­le­vi­ate HF symp­toms, im­prove ex­er­cise I C
ca­pac­i­ty, and re­duce HF hos­pi­tal­iza­tions.

ARB

An ARBc is rec­om­mend­ed to re­duce the risk of HF hos­pi­tal­iza­tion and


CV death in symp­to­matic pa­tients un­able to tol­er­ate an ACE-​I or ARNI I B
(pa­tients should also re­ceive a beta-​block­er and an MRA).

If-​chan­nel in­hibitor

Ivabra­dine should be con­sid­ered in symp­to­matic pa­tients with LVEF IIa B


≤35%, in SR and a rest­ing heart rate ≥70 bpm de­spite treat­ment with
an ev­i­dence-​based dose of beta-​block­er (or max­i­mum tol­er­at­ed dose
be­low that), ACE-​I (or ARNI) and an MRA, to re­duce the risk of HF
hos­pi­tal­iza­tion and CV death.

Ivabra­dine should be con­sid­ered in symp­to­matic pa­tients with LVEF


≤35%, in SR and a rest­ing heart rate ≥70 bpm who are un­able to tol­er­‐
ate or have con­traindi­ca­tions for a beta-​block­er to re­duce the risk of IIa C
HF hos­pi­tal­iza­tion and CV death. Pa­tients should also re­ceive an
ACE-​I (or ARNI) and an MRA.

Sol­ub
­ le guany­late cy­clase stim­ul­a­tor

Veri­ciguat may be con­sid­ered in pa­tients in NYHA class II-​IV who


have had wors­en­ing HF de­spite treat­ment with an ACE-​I (or ARNI), a
IIb B
beta-​block­er and an MRA to re­duce the risk of CV mor­tal­i­ty or HF
hos­pi­tal­iza­tion.

Hy­dralazine and isosor­bide dini­trate

Hy­dralazine and isosor­bide dini­trate should be con­sid­ered in self-​


iden­ti­fied black pa­tients with LVEF ≤35% or with an LVEF <45% com­‐
bined with a di­lat­ed left ven­tri­cle in NYHA class III-​IV de­spite treat­‐ IIa B
ment with an ACE-​I (or ARNI), a beta-​block­er and an MRA to re­duce
the risk of HF hos­pi­tal­iza­tion and death.

Hy­dralazine and isosor­bide dini­trate may be con­sid­ered in pa­tients


with symp­to­matic HFrEF who can­not tol­er­ate any of an ACE-​I, an IIb B
ARB, or ARNI (or they are con­traindi­cat­ed) to re­duce the risk of death.

Digox­in

Digox­in may be con­sid­ered in pa­tients with symp­to­matic HFrEF in SR


de­spite treat­ment with an ACE-​I (or ARNI), a beta-​block­er and an
IIb B
MRA, to re­duce the risk of hos­pi­tal­iza­tion (both all-​cause and HF hos­‐
pi­tal­iza­tions).

ACE-​I = an­giotensin-​con­vert­ing en­zyme in­hibitor; ARB = an­giotensin-​re­cep­tor block­er; ARNI = an­giotensin re­cep­tor-​neprilysin in­hibitor;
CV = car­dio­vas­cu­lar; HF = heart fail­ure; HFrEF = heart fail­ure with re­duced ejec­tion frac­tion; LVEF = left ven­tric­u­lar ejec­tion frac­tion;
MRA = min­er­alo­cor­ti­coid re­cep­tor an­tag­o­nist; NYHA = New York Heart As­so­ci­a­tion; SR = si­nus rhythm.
a
Class of recommendation. bLev­el of ev­i­dence.
c
The ARBs with ev­i­dence in HFrEF are can­desar­tan, losar­tan and val­sar­tan.

In ad­di­tion to the gen­er­al ther­a­pies con­sid­ered in Sec­tion Cardiac rhythm management for heart failure with reduced
ejection fraction, oth­er ther­a­pies are ap­pro­pri­ate to con­sid­er in se­lect­ed pa­tients. These are cov­ered in de­tail in lat­er sec­‐
tions. Some of the main ones (i.e. those with Class I and IIa Mor­tal­i­ty/​Hos­pi­tal­iza­tion in­di­ca­tions) are de­pict­ed in Fig­ure 3.

Fig­ure 3 Strate­gic phe­no­typ­ic overview of the man­age­ment of heart fail­ure with re­duced ejec­tion frac­tion

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