Welcome to PracticeUpdate! We hope you are enjoying access to a selection of our top-read and most recent articles. Please register today for a free account and gain full access to all of our expert-selected content.
Already Have An Account? Log in Now
2024 ACC Expert Consensus Decision Pathway for the Treatment of HFrEF
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersThe 2021 Update to the 2017 American College of Cardiology (ACC) Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction provided a practical, streamlined resource for clinicians managing patients with heart failure with reduced ejection fraction (HFrEF). The expert consensus decision pathway (ECDP) provided guidance on introducing the numerous evidence-based therapies, improving adherence, overcoming treatment barriers, acknowledging contraindications and situations for which little data exist, affording expensive therapies, treating special cohorts, and making the transition to palliative care. Rather than focusing on extensive text, the document provided practical tips, tables, and figures to make clear the steps, tools, and provisos needed to treat the patient with HFrEF successfully and expeditiously. Many of the pivotal issues addressed in the ECDP were not the substance of clinical trials; rather, they represent the challenge of clinical practice.
Since publication of the 2021 ECDP, new data have developed that necessitate an update to the ECDP, including publication of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. This update thus serves as updated guidance to clinicians based on contemporary knowledge. The treatment of HFrEF can feel overwhelming, and many opportunities to improve patient outcomes are being missed; hopefully, this ECDP will streamline care to realize the best possible patient outcomes in HF (heart failure).
Additional Info
Disclosure statements are available on the authors' profiles:
2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee
J Am Coll Cardiol 2024 Apr 16;83(15)1444-1488, TM Maddox, JL Januzzi, LA Allen, K Breathett, S Brouse, J Butler, LL Davis, GC Fonarow, NE Ibrahim, J Lindenfeld, FA Masoudi, SR Motiwala, E Oliveros, MN Walsh, A Wasserman, CW Yancy, QR YoumansFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
2024 CHF guidelines for heart failure with reduced ejection fraction
These updated expert-driven guidelines stress four medications for HFrEF <40%. Once congestion is controlled with a loop diuretic, the guidelines recommend the implementation of an angiotensin receptor/neprilysin inhibitor (ARNI), beta blocker, mineralocorticoid antagonist, and an SGLT2 inhibitor. This combination of medications increases years of survival and reduces cardiac-related mortality and rehospitalization.
If someone is newly diagnosed with HFrEF, these four drugs should be titrated up to target doses within 3 months of the diagnosis.
Drug
Starting Dose
Target Dose
CHF Tx Target
Loop diuretic
Titrate as needed
Congestion (orthopnea, rales, pedal edema, etc)
ARNI
24/26 mg to 49/51 mg twice daily
97/103 mg twice daily
Renin-angiotensin-aldosterone system
Natriuretic and other vasodilator peptides
Beta blocker
1.25 mg daily
12.5-25 mg daily
10 mg daily
200 mg daily
Sympathetic nervous system
Elevated heart rate
Mineralocorticoid antagonist
25 mg daily
12.5-25 mg daily
50 mg daily
25-50 mg daily
Renin-angiotensin-aldosterone system
SGLT inhibitors
10 mg daily
10 mg daily
10 mg daily
10 mg daily
Sodium-glucose cotransporters
Reduces sodium retention
Once congestion is brought under control with a loop diuretic, the addition of these four medications may allow lowering the diuretic dose or stopping it completely.
If the patient is on an angiotensin-converting enzyme (ACE) inhibitor and you want to start an ARNI, you should have a washout period when the ACE inhibitor is stopped for 3 days before the ARNI is started to reduce the risk of angioedema. This is not necessary if you are switching from an angiotensin-receptor blocker (ARB) to an ARNI. If the patient has a history of angioedema or cannot afford an ARNI, an ARB should be used instead. (Note: you could also use an ACE inhibitor but since an ARB works as well with fewer side effects [cough], you may want to use an ARB since both ACE inhibitors and ARBs are now generic.)
An ARNI can cause hypotension and should be titrated slowly with blood pressure monitoring. Reducing the dose of a loop diuretic may be advised when starting an ARNI.
If the beta blocker does not control heart rate (the goal is ~70 beats/min) or the patient does not tolerate high doses of the beta blocker, consider using ivabradine in place of it for individuals in sinus rhythm.
SGLT2 inhibitors have a modest blood pressure–lowering effect and may be more ideal in individuals with low systolic blood pressure. Remember that, when this drug is started, the glomerular filtration rate will drop due to an increase in the afferent glomerular tone. But, even with this reduction of glomerular filtration rate, this class of drugs has been found to reduce the progression of chronic kidney disease. SGLT2 inhibitors also reduce the risk of hyperkalemia with mineralocorticoid antagonists.
In individuals who remain symptomatic or have NYHA functional class III to IV symptoms, adding hydralazine and isosorbide dinitrate therapy would be the next step. The authors state that this may be particularly helpful in African American patients.