Update on Managing Heart Failure in Primary Care

Neil Skolnik, MD


June 15, 2022

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today we're going to talk about the new American Heart Association/American College of Cardiology guidelines on the treatment of heart failure. In addition to giving us strong evidence-based guidance, these new guidelines also discuss two new categories of heart failure (HF).

Let's start with diagnosis. It's symptoms, an echocardiogram, and a B-type natriuretic peptide (BNP) or N-terminal prohormone of BNP (NT-proBNP) level. The criteria for enrollment in the heart failure trials from a symptom point of view were the New York Heart Association (NYHA) class II symptoms: Ordinary physical activity causes fatigue, dyspnea, or lightheadedness. So it doesn't take a whole lot to opt in with regard to symptoms. In terms of testing, it's an echocardiogram showing either systolic or diastolic dysfunction and an elevated BNP or NT-proBNP.

Heart Failure With Reduced Ejection Fraction

Let's go on now to treatment starting with heart failure with reduced ejection fraction (HFrEF). This is defined as an ejection fraction (EF) ≤ 40%. Guideline-directed medical therapy includes four classes of NYHA class I medicines, meaning the evidence to support their use is strong:

  • Renin-angiotensin system (RAS) inhibitors with either an angiotensin receptor/neprilysin inhibitor (ARNI) which combines an angiotensin-receptor blocker (ARB) with a neprilysin inhibitor or an angiotensin-converting enzyme inhibitor (ACEI), with a preference for an ARNI

  • Beta-blockers (bisoprolol, carvedilol, or sustained-release metoprolol succinate)

  • Mineralocorticoid receptor antagonists (MRA), either spironolactone or eplerenone

  • SGLT2 inhibitors which are recommended now, whether or not the patient has diabetes

It's important to use all four classes of medicines in patients with HFrEF. Some will also need diuretics for fluid overload. Make sure to refer patients to cardiology if they have an EF≤ 35% for consideration of implantable defibrillator (ICD) placement.

Heart Failure With Preserved Ejection Fraction

The most exciting new area, for those of us in primary care, is the recommendation for HF with preserved EF (HFpEF), which is defined as an EF ≥ 50%. This is exciting for two reasons. Previously, there simply were no evidence-based therapies for HFpEF that changed outcomes. Second, we are going to be seeing a lot more HFpEF once we start looking for it, especially in patients with hypertension, diabetes, or obesity who have NYHA class II symptoms (dyspnea on exertion).

Treatment recommendations for HFpEF include a grade 2a (moderate) level of evidence for the SGLT2 inhibitors, which have been shown to decrease HF hospitalizations and cardiovascular mortality. Note that the SGLT2 inhibitors are now recommended across the spectrum of HF. Grade 2b (weak) level of evidence supports the use of MRAs, ARNIs, and ARBs in selected patients whose EFs are on the lower end of the preserved range.

New Categories of Heart Failure

The first new category is HF with mildly reduced EF (between 41% and 49%). There are two grade 2a recommendation for adults: Consider the use of RAS blockers (ARNI, ACEI, or ARB) and MRAs particularly for patients on the lower end of the spectrum of mildly reduced EF.

The other new category is HF with improved EF. They've clarified that in patients with HFrEF, whose EF improves to > 40%, guideline-directed medical therapy for HFrEF should be continued to prevent relapse, even if the patients are asymptomatic.

This is a lot of new and important information for a clinical problem where our treatment makes a big difference. I'm Neil Skolnik, and this is Medscape.

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