This Pathway Is For Outpatient Heart Failure: Links To And Excerpts From “2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction” With Links To Additional Resources

In this post I link to and excerpt from 2017 ACC Expert Consensus Decision
Pathway for Optimization of Heart Failure Treatment: Answers to
10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction.
A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways [PubMed Abstract]* [Full Text HTML] [Full Text PDF]. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 71, NO. 2, 2018.

*This PubMed Abstract has links to similar articles. [For the list, please see my post Additional Articles On Heart Failure Treatment From The AHA and ACC
Posted on July 7, 2020 by Tom Wade MD

*This PubMed Abstract has links to articles that cite the above article: See all “Cited by” articles

From the article:

Although some of the recommendations may be
relevant to patients hospitalized with acute HF, this
document mainly deals with the management of
patients with chronic ambulatory HFrEF. [Emphasis Added]

 

And here are excerpts from 2017 ACC Expert Consensus Decision
Pathway for Optimization of Heart Failure Treatment: Answers to
10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction:

Abstract

The care of patients with HF is more involved than ever. Current care for the patient with HF with reduced ejection fraction (EF) includes no fewer than 7 evidence-based medications, 3 evidence-based device strategies, and a number of recommend processes of care. The opportunity to change the natural history of HF with reduced EF has never been better, but with more choices comes greater complexity.

1. INTRODUCTION

HF exists in several phenotypes, in part reflected by
differences in left ventricular ejection fraction (LVEF).
These include heart failure with reduced ejection fraction
(HFrEF), HF with preserved EF, as well as HF with
improved EF. Although the evidence base for the treatment of HFrEF has expanded substantially, much work
remains for the other forms of HF. New therapies for HF
with preserved EF are under exploration, and the evidence
base addressing HF with improved EF is just emerging.

The purpose of this document is to complement
the 2017 ACC/AHA/HFSA Focused Update of the 2013
ACC/AHA Guideline for the Management of Heart Failure (1) by addressing new medical therapies, prevention, and comorbidities relevant to HFrEF for which data are available.

Ten Pivotal Issues in HFrEF

1. How to initiate, add, or switch therapy to new
evidence-based guideline-directed treatments for
HFrEF.
2. How to achieve optimal therapy given multiple drugs
for HF including augmented clinical assessment that
may trigger additional changes in guideline-directed
therapy (e.g., imaging data, biomarkers, and filling
pressures).
3. When to refer to an HF specialist.
4. How to address challenges of care coordination.
5. How to improve adherence.
6. What is needed in specific patient cohorts: African
Americans, the frail, and older adults.
7. How to manage your patients’ cost of care for HF.
8. How to manage the increasing complexity of HF.
9. How to manage common comorbidities.
10. How to integrate palliative care and transition to
hospice care.

2. METHODS

[See this section in the article.]

3. ASSUMPTIONS AND DEFINITIONS

General Clinical Assumptions

1. Although many topics are generalizable to all
patients with HF, the focus of this effort, including
pathway recommendations, only applies to patients
with HFrEF.
2. Although some of the recommendations may be
relevant to patients hospitalized with acute HF, this
document mainly deals with the management of
patients with chronic ambulatory HFrEF.                             3. The expert consensus writing committee endorses
the evidence-based approaches to HF therapy and
management enumerated in the 2013 ACC/AHA Guideline for the Management of Heart Failure (2) and the
2016 and 2017 ACC/AHA/HFSA focused updates (1,3).
4. These algorithms assume the clinician will seek input
as needed from a pharmacist, cardiologist, HF
specialist and/or disease management program, and
other relevant medical specialist (e.g., endocrinologist
or nephrologist) to guide clinical management, and will
consider patient preference in all clinical decisionmaking.
5. These algorithms are based on best available data; all
clinical decisions should be governed by judgment and
influenced by discussions with the patient about
treatment preferences.
6. At any point in time, these suggestions and algorithms
may be superseded by new data.

Definitions

HFrEF: Clinical diagnosis of HF and LVEF ≤40%.
New York Heart Association (NYHA) functional
classification:

  • Class I: No limitation of physical activity. Ordinary
    physical activity does not cause symptoms of HF.
  • Class II: Slight limitation of physical activity.
    Comfortable at rest, but ordinary physical activity results in symptoms of HF.
  • Class III: Marked limitation of physical activity.
    Comfortable at rest, but less than ordinary activity
    causes symptoms of HF.
  • n Class IV: Unable to perform any physical activity
    without symptoms of HF, or symptoms of HF at rest.

GDMT: Guideline-directed medical therapy.
Optimal therapy: Treatment provided at either the target
or the highest-tolerated dose for a given patient.
Target dose: Doses targeted in clinical trials.
ACC/AHA Stages of HF:

  1. Stage A: At high risk for HF but without structural heart disease or symptoms of HF.
  2. Stage B: Structural heart disease but without signs or
    symptoms of HF.
  3. Stage C: Structural heart disease with prior or current symptoms of HF.
  4. Stage D: Refractory HF requiring specialized interventions.

4. PATHWAY SUMMARY GRAPHIC

Figure 1 summarizes the 2017 ACC Expert Consensus
Decision Pathway for Optimization of Heart Failure
Treatment: Answers to 10 Pivotal Issues About Heart
Failure With Reduced Ejection Fraction.

5. DESCRIPTION AND RATIONALE:
ANSWERS TO 10 PIVOTAL ISSUES IN HF

[Note to myself: Review the answers to the 10 Pivotal Issues In Heart Failure in the article.]

ANSWERS TO 10 PIVOTAL ISSUES IN HF …….. 205
1. How to Initiate, Add, or Switch to New
Evidence-Based Guideline-Directed Therapy
for HFrEF …………………………… 205
2. How to Achieve Optimal Therapy Given Multiple
Drugs for HF Including Augmented Clinical
Assessment That May Trigger Additional Changes
in GDMT (e.g., Imaging Data, Biomarkers,
and Filling Pressures) ………………….. 211
3. When to Refer to an HF Specialist …………. 215
4. How to Address Challenges of Care Coordination . 215
5. How to Improve Adherence ……………… 216
6. What Is Needed in Specific Patient Cohorts:
African Americans, the Frail, and Older Adults … 218
7. How to Manage Your Patients’ Cost of Care for HF 219
8. How to Manage the Increasing Complexity of HF . 220
9. How to Manage Common Comorbidities …….. 222
10. How to Integrate Palliative Care and Transition to
Hospice Care ………………………… 222

1. How to initiate, add, or switch therapy to new evidence-based guideline-directed treatments for HFrEF.

ARNI – angiotensin receptor – neprilysin inhibitor: Sacubitril/Valsartan from StatPearls:

Sacubitril/valsartan is the first agent to be approved in a new class of drugs called angiotensin receptor neprilysin inhibitor (ARNI). The medication is FDA-approved for the treatment of patients with chronic heart failure with reduced ejection fraction (HFrEF) with NYHA class II, III, or IV. Sacubitril/valsartan is to be used in place of an ACEI or angiotensin II receptor blocker (ARB) and in conjunction with other standard, heart-failure treatments (beta blocker, aldosterone antagonist).[1][2][3]

According to the 2016 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America (ACC/AHA/HFSA) Focused Update on New Pharmacological Therapy for Heart Failure, ACEI, ARB, or ARNI are now recommended in patients with chronic symptomatic HFrEF to reduce morbidity and mortality (class I recommendation).

Patients must be able to tolerate ACEI or ARB prior to being started on sacubitril/valsartan.[4]

 

Ivabradine

Heart rate independently predicts outcomes in HFrEF. Evidence from beta-blocker trials suggests that heart rate lowering is directly related to improved outcomes (10). A dose-response relationship for evidence-based beta blockers used in HFrEF has been demonstrated (i.e., the higher the dose, the better the outcome). Prior to initiating any other agent with heart-rate slowing effects, the dose of an evidence-based beta blocker should be optimized. However, some apparently well-compensated patients on optimal beta blocker therapy continue to have a persistent resting heart rate over 70 bpm.

Ivabradine is an adjunctive means to reduce heart rate in
patients with chronic HFrEF who are in sinus rhythm. Ivabradine is a specific inhibitor of the If current involved in sinoatrial nodal activity and reduces the heart rate of patients in normal sinus rhythm without lowering blood pressure. In the SHIFT (Systolic HF Treatment with the If Inhibitor Ivabradine Trial) trial of 6,505 subjects with stable, chronic, predominantly NYHA class II and III HFrEF, ivabradine therapy, when added to GDMT, resulted in a significant reduction in HF hospitalizations (11). Benefits were noted especially for those patients with: contraindications to beta blockers, beta blocker doses <50% of GDMT targets (12), and resting heart rate $77 bpm at study entry (13). 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 (11).

In the 2016 ACC/AHA/HFSA HF guidelines focused
update (3), ivabradine was recommended as a Class IIa,
Level of Evidence: B-R (1,2) therapy to reduce the risk of
HF hospitalization in patients with HFrEF (LVEF #35%)
already receiving GDMT (including a beta blocker at
maximally tolerated dose), and who are in sinus rhythm
with a heart rate greater than 70 bpm at rest (Figures 2 and 3,
Tables 1 and 5). The contraindications to ivabradine are
enumerated in Table 4.

Consensus Pathway Algorithm for Initiation and
Titration of HFrEF Therapies

A strategy for initiating and titrating evidence-based
therapies for patients with HFrEF is depicted in Figures 2
and 3. As noted in the previous text, after a diagnosis of
HF is made, GDMT should be initiated and therapies should
be adjusted no more frequently than every 2 weeks to
target doses (or maximally tolerated doses). Clinicians
should aim to achieve this within 3 to 6 months of an initial
diagnosis of HF (however, this rapid timeline may not be
logistically feasible for some patients). GDMT should
continue to be up-titrated to achieve maximally tolerated
doses of these therapies. During follow-up, frequent reassessment of the clinical status of the patient, blood pressure, and kidney function (and electrolytes) should be performed. Reassessment of ventricular function should occur after target or maximally tolerated doses of GDMT are achieved for 3 months to determine the need for device
therapies such as implantable defibrillators and cardiac
resynchronization therapy (2). Structured medication titration plans embedded in disease management programs have been shown to be useful in obtaining target doses of GDMT within 6 months of hospital discharge (14)

2. How to Achieve Optimal Therapy Given Multiple Drugs for
HF Including Augmented Clinical Assessment That May
Trigger Additional Changes in GDMT (e.g., Imaging Data,
Biomarkers, and Filling Pressures)

Start here.

 

 

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