COMMENTARY

'Think Twice' Before Stopping Heart Failure Meds

Ileana L. Piña, MD, MPH

Disclosures

April 29, 2019

This transcript has been edited for clarity.

Hello. This is Ileana Piña from Detroit Medical Center and Wayne State University.

I want to talk about withdrawal of guideline-directed medical therapy. I have often said on this blog that I really shy away from stopping the medications, even when patients get better, showing a normal ejection fraction (EF) and a shrunken ventricle. Patients often say, "Don't you want to stop anything?" Primary care physicians may ask, "Can I stop the spironolactone, beta-blocker, or renin-angiotensin aldosterone blocker (ie, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, angiotensin receptor/neprilysin inhibitor)?"

Those are the three foundational drugs that we use.

We are starting to get some view into this. Martin Cowie's group in the United Kingdom recently published a study called TRED-HF.[1] They took 51 patients with heart failure with reduced EF (HFrEF) who had improved—they had shrunken the ventricle and their EFs had gone up. Patients were divided into two groups: 26 patients remained on the same drugs, 25 patients were assigned to treatment withdrawal. They looked at the patients again 6 months later. In patients who had therapy withdrawn, a good number of them regressed. They defined the regression as a drop in 10% or more of EF or they had a limit on changes in the ventricular function.

We are seeing data finding that you [should] not do that. Many of us who have been taking care of these patients for years know that when patients stop the drugs or become nonadherent, many of them revert right back.

Another very interesting report that recently appeared in JACC: Heart Failure talked about initiation, continuation, and withdrawal of therapy.[2] This group looked at Get With The Guidelines, where you can actually see what therapies patients are going home on and whether the drugs had been started in the hospital. Patients who were started on therapy in the hospital and stayed on it seemed to have better outcomes. I find the withdrawal group very intriguing. Some curves in that paper show that patients withdrawn from the drugs do not do so well and have higher mortality and event rates.

Why is that? Are those the patients who are skidding, in whom we should be thinking about advanced therapies? Or are those maybe the patients whose creatinine went up a bit so clinicians are taking the drugs away or they're not uptitrating the drugs? Creatinine going up a bit, however, did not affect outcomes.

Think twice before pulling back therapy because you may lose the good benefits that you had. It is a conversation you must have with patients to tell them why you are hesitant to stop the drugs. Make it easy for them; make the drugs once a day if you have to, but just do not stop them.

Thank you for your time. This is Ileana Piña, signing off.

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