Updated ACC decision pathway embraces new heart failure treatment strategies



A newly updated expert consensus from the American College of Cardiology for management of heart failure with reduced ejection fraction includes several new guideline-directed medical therapies among other substantial changes relative to its 2017 predecessor.

Dr. Gregg C. Fonarow interim chief of cardiology UCLA

Dr. Gregg C. Fonarow

The advances in treatment of heart failure with reduced ejection fraction (HFrEF) have resulted in a substantial increase in complexity in reaching treatment goals, according to the authors of the new guidance. Structured similarly to the 2017 ACC Expert Consensus Decision Pathway, the update accommodates a series of practical tips to bring all patients on board with the newer as well as the established therapies with lifesaving potential.

The potential return from implementing these recommendations is not trivial. Relative to an ACE inhibitor and a beta-blocker alone, optimal implementation of the current guideline-directed medical therapies (GDMT) “can extend medical survival by more than 6 years,” according to Gregg C. Fonarow, MD, chief of cardiology at the University of California, Los Angeles.

A member of the writing committee for the 2021 update, Dr. Fonarow explained that the consensus pathway is more than a list of therapies and recommended doses. The detailed advice on how to overcome the barriers to GDMT is meant to close the substantial gap between current practice and unmet opportunities for inhibiting HFrEF progression.

“Optimal GDMT among HFrEF patients is distressingly low, due in part to the number and complexity of medications that now constitute GDMT,” said the chair of the writing committee, Thomas M. Maddox, MD, executive director, Healthcare Innovation Lab, BJC HealthCare/Washington University, St. Louis. Like Dr. Fonarow, Dr. Maddox emphasized that the importance of the update for the practical strategies it offers to place patients on optimal care.

Dr. Thomas M. Maddox, executive director, Healthcare Innovation Lab, BJC HealthCare/Washington University, St. Louis.

In the 2017 guidance, 10 pivotal issues were tackled, ranging from advice of how to put HFrEF patients on the multiple drugs that now constitute optimal therapy to when to transition patients to hospice care. The 2021 update covers the same ground but incorporates new information that has changed the definition of optimal care.

Perhaps most importantly, sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor (ARNi), and SGLT2 inhibitors represent major new additions in HFrEF GDMT. Dr. Maddox called the practical information about how these should be incorporated into HFrEF management represents one of the “major highlights” of the update.

Two algorithms outline the expert consensus recommendations of the order and the dose of the multiple drugs that now constitute the current GDMT. With the goal of explaining exactly how to place patients on all the HFrEF therapies associated with improved outcome, “I think these figures can really help us in guiding our patients to optimal medication regimens and dosages,” Dr. Maddox said. If successful, clinicians “can make a significant difference in these patients’ length and quality of life.”

Most cardiologists and others who treat HFrEF are likely aware of the major improvements in outcome documented in large trials when an ARNi and a SGLT2 inhibitor were added to previously established GDMT, but the update like the 2017 document is focused on the practical strategies of implementation, according to Larry A. Allen, MD, medical director of advanced heart failure at the University of Colorado at Denver, Aurora.

“The 2017 Expert Consensus Decision Pathway got a lot of attention because it takes a very practical approach to questions that clinicians and their patients have to tackle everyday but for which there was not always clean answers from the data,” said Dr. Allen, a member of the writing committee for both the 2017 expert consensus and the 2021 update. He noted that the earlier document was one of the most downloaded articles from the ACC’s journal in the year it appeared.

“There is excellent data on the benefits of beta-blockers, ARNi, mineralocorticoid antagonists, and SGLT2 inhibitors, but how does one decide what order to use them in?” Dr. Allen asked in outlining goals of the expert consensus.

While the new update “focuses on the newer drug classes, particularly SGLT2 inhibitors,” it traces care from first-line therapies to end-of-life management, according to Dr. Allen. This includes information on when to consider advanced therapies, such as left ventricular assist devices or transplant in order to get patients to these treatments before the opportunity for benefit is missed.

Both the 2017 version and the update offer a table to summarize triggers for referral. The complexity of individualizing care in a group of patients likely to have variable manifestations of disease and multiple comorbidities was a theme of the 2017 document that has been reprised in the 2021 update,

“Good communication and team-based care” is one of common management gaps that the update addresses, Dr. Allen said. He indicated that the checklists and algorithms in the update would help with complex decision-making and encourage the multidisciplinary care that ensures optimal management.

SOURCE: Maddox TM et al. J Am Coll Cardiol. 2021 Jan 11. doi: 10.1016/j.jacc.2020.11.022.

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