From the Journals

ACC guidance addresses newer HFrEF options



It might be prudent to monitor N-terminal pro–B-type natriuretic peptide (NT-proBNP) and skip natriuretic peptide measures in heart failure patients on sacubitril/valsartan (Entresto), according to a new expert consensus document from the American College of Cardiology on managing heart failure with reduced ejection fraction.

“While rising natriuretic peptide concentrations are correlated with adverse outcomes, this relationship can be confounded with the use of sacubitril/valsartan. Due to neprilysin inhibition, concentrations of BNP rise in patients treated with sacubitril/valsartan and tend not to return to baseline despite chronic therapy. In contrast, NT-proBNP concentrations typically decrease, as NT-proBNP is not a substrate for neprilysin,” explained authors led by heart failure pathway writing committee chairman Clyde W. Yancy, MD, chief of cardiology at Northwestern University in Chicago (J Am Coll Cardiol. 2017 Dec 22. doi: 10.1016/j.jacc.2017.11.025).

Dr. Clyde W. Yancy

Dr. Clyde W. Yancy

It’s just one of scores of tips in “2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction.” The document is meant to complement the 2017 heart failure (HF) guidelines published jointly by the ACC, the American Heart Association, and the Heart Failure Society of America (J Am Coll Cardiol. 2017 Aug 8;70(6):776-803. doi: 10.1016/j.jacc.2017.04.025)

Treatment of heart failure with reduced ejection fraction (HFrEF) “can feel overwhelming, and many opportunities to improve patient outcomes are being missed; hopefully, this Expert Consensus Decision Pathway may streamline care to realize best possible patient outcomes,” the authors wrote.

The 10 issues and their detailed answers address therapeutic options, adherence, treatment barriers, drug costs, special populations, and palliative care. The document is full of tables and figures of treatment algorithms, drug doses, and other matters.

There’s a good deal of advice about using two newer HFrEF options: sacubitril/valsartan and ivabradine (Corlanor). Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ANRI), is a switch agent for patients who tolerate but remain symptomatic on ACE inhibitors (ACEIs) or angiotensin II receptor blockers (ARB). Moving over to sacubitril/valsartan has been shown to decrease the risk of hospitalization and death.

Switching from an ACEI requires a 36-hour washout period to avoid angdioedema; no washout is needed for ARB switches. Sacubitril/valsartan doses can be increased every 2-4 weeks to allow time for adjustment to vasodilatory effects. In one study, gradual titration over about 6 weeks maximized attainment of target dosages. As with ACEIs and ARBs, titration might require lowering loop diuretic doses, with careful attention paid to potassium concentrations.

“The committee is aware that clinicians may occasionally consider initiating ANRI in patients who have not previously been treated with an ACEI or ARB. To be explicitly clear, no predicate data supports this approach,” but it “might be considered” if patients are well informed of the risks, including angioedema and hypotension, the committee wrote.

Ivabradine is for patients whose resting heart rate is at or above 70 bpm despite maximal beta-blocker treatment. “It is important to emphasize that ivabradine is indicated only for patients in sinus rhythm, not in those with atrial fibrillation, patients who are 100% atrially paced, or unstable patients. From a safety standpoint, patients treated with ivabradine had more bradycardia and developed more atrial fibrillation as well as transient blurring of vision,” according to the consensus document.

Turning to wireless implantable pulmonary artery pressure monitoring, another newer approach, the group noted that, compared with standard care, it reduced hospitalization and led to more frequent adjustment of diuretic doses, suggesting a benefit “in well-selected patients with recurrent congestion. … The impact on mortality is unknown.”

“For a number of reasons,” hydralazine/isosorbide dinitrate “is often neglected in eligible patients. However, given the benefits of this combination (43% relative reduction in mortality and 33% relative reduction in HF hospitalization), African-American patients should receive these drugs once target or maximally tolerated doses of beta-blocker and ACEI/ ARB/ARNI are achieved. This is especially important for those patients with [New York Heart Association] class III to IV symptoms,” the committee members said.

Regarding treatment adherence, the group noted that “monetary incentives or other rewards for adherence to medications may be cost saving for highly efficacious and inexpensive drugs such as beta-blockers.”

The work was supported by the ACC with no industry funding. Dr. Yancy had no disclosures.

SOURCE: Yancy C et. al. J Am Coll Cardiol. 2017 Dec 22. doi: 10.1016/j.jacc.2017.11.025

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