The American Heart Association, the American College of Cardiology, and the Heart Failure Society of America updated their guideline for the management of heart failure in 2022. Which of the following statements is an important takeaway from this new guideline?
- □ (A) Patients with prior heart failure but now with left ventricular ejection fraction (LVEF) improved to greater than 40% can discontinue their heart failure treatment.
- □ (B) Evidence of increased filling pressure is not important in the diagnosis of heart failure if LVEF is greater than 40%.
- □ (C) Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended in patients with coronary artery disease as primary prevention for heart failure.
The American Heart Association and the American College of Cardiology, with the Heart Failure Society of America, recently updated their joint practice guideline for the management of heart failure. Most notable in their top take-home messages is the inclusion of SGLT2i, which are recommended in all classes of heart failure, including the prevention of heart failure in at-risk patients. Three other medication categories given class 1A recommendation in the management of heart failure with reduced ejection fraction (HFrEF) include:
- Renin-angiotensin system inhibitors (e.g., angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and angiotensin receptor-neprilysin inhibitors)
- β-blockers (e.g., bisoprolol, carvedilol, and sustained-release metoprolol)
- Mineralocorticoid receptor antagonists (e.g., spironolactone and eplerenone)
SGLT2i are a new class of oral hypoglycemics initially used to help lower blood sugar in patients with type 2 diabetes by reducing the reabsorption of sodium and glucose at the proximal renal tubules. SGLT2i medications approved by the U.S. Food and Drug Administration (FDA) include canagliflozin, dapagliflozin, ertugliflozin, and empagliflozin. Proposed mechanisms of cardiovascular benefit include the promotion of osmotic diuresis and natriuresis in reducing preload, vascular vasodilatory effects reducing afterload, and improvement in cardiac metabolism.
The new guideline expands the classification of heart failure to include an initial assessment of heart failure with mildly reduced ejection fraction (HFmrEF) with an LVEF of 41% to 49%, which appears between HFrEF with an LVEF of 40% or less and heart failure with preserved ejection fraction (HFpEF) with an LVEF of 50% or greater. Serial assessment and reclassification may identify improvement in cardiac function in those who started with HFrEF, but despite this improvement, those patients should continue their heart failure regimen even if their LVEF is greater than 40%.
In patients with HFmrEF and HFpEF, SGLT2i are a class 2a recommendation — higher than β-blockers, angiotensin system inhibitors, and mineralocorticoid receptor antagonists. In patients with HFpEF, treatment of hypertension is important, and management of atrial fibrillation can be useful in improving symptoms. In patients with seemingly normal ejection fraction, evidence of spontaneous or provokable increase in filling pressure is important in the diagnosis of heart failure if LVEF is greater than 40%. This could be observed by elevated levels of natriuretic peptide, diastolic dysfunction on imaging, or abnormal invasive hemodynamic measurements.
Finally, primary prevention of heart failure is now a focus of the guideline. Patients with iron deficiency, anemia, hypertension, type 2 diabetes, sleep disorders, atrial fibrillation, and malignancy are considered at risk. The guideline endorses getting regular physical activity, maintaining a normal weight, controlling blood pressure, and consuming a healthy diet. SGLT2i are recommended for patients with type 2 diabetes in combination with coronary artery disease or with a cardiovascular risk that is considered high. Patients with advanced heart failure should be referred to a team specializing in heart failure to prolong survival. There is more consideration of invasive techniques such as atrial fibrillation ablation and resynchronization therapies, implantable devices, cardiac transplantation, and mitral valve clipping in patients with heart failure and secondary mitral regurgitation.
This new guideline is a major change in the management of heart failure, stressing SGLT2i heavily. Of note, around the time of this guideline’s release, the FDA released a warning to health care professionals to consider stopping canagliflozin, dapagliflozin, and empagliflozin at least three days preoperatively and ertugliflozin at least four days preoperatively because of the risk of ketoacidosis after surgery.