ACC’s HFrEF Update Includes ARNI, SGLT2 Inhibitor Trials Plus Tips for Care

The American College of Cardiology (ACC) has released revised guidance for optimizing the treatment of patients who have heart failure with reduced ejection fraction (HFrEF). It updates a similar 2017 consensus document, with an eye toward the recent science and important patient-centric issues.

Writing committee chair Thomas M. Maddox, MD (Washington University School of Medicine, St. Louis, MO), said it was time for an update, given the success of therapeutic trials in HFrEF patients such as PARADIGM-HF, in which the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan (Entresto; Novartis) reduced the risk of all-cause mortality and HF hospitalization, as well as a range of gliflozin trials showing that sodium-glucose cotransporter 2 (SGLT2) inhibitors lower rates of CV events, mortality, and adverse renal outcomes on top of existing therapies.

“The robustness of the literature was promoting these two medical classes to be first-line, top-of-mind therapies, and we felt like that growing data supporting their use needed to be called out and highlighted in this document,’ he told TCTMD. Maddox added that the committee sought to make the paper as user-friendly as possible for busy clinicians trying to keep up with the many available therapies now being used for HF. They created a treatment algorithm for guideline-directed medical therapies that includes novel medications, as well as suggestions for adding and titrating various drugs.

For now, the document will serve as interim guidance in anticipation of ACC’s full guideline update down the road. The 2021 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction was published today in the Journal of the American College of Cardiology.

Practical Help From a Diverse Committee

The committee set out to address 10 key treatment and management issues. In addition to managing therapies effectively, the issues include when to refer to a specialist; challenges of care coordination; improving medication adherence; managing specific populations including African Americans, older adults, and frail elderly individuals; managing comorbidities; and integrating palliative and hospice care.

Maddox said one of the strengths of the writing and oversight committee that put together the document is that it was populated with healthcare providers with diverse backgrounds and experiences, which helped in areas where they needed to dig deeper to provide the best practical advice. Regarding the issue of improving medication adherence, for example, the committee came up with 10 suggestions that include referral to ACC decision aids like CardioSmart and examples of questions that should be asked at office visits to routinely monitor adherence (“How many times in a week do you miss taking your medications?” “Have you run out of your medications recently?”).

Early initiation of guideline-directed medical therapy and achievement of targets is a persistent theme throughout the document. The committee created multiple figures and tables, including a guide to 12 important pathophysiological targets, the modulation of which has been shown to improve symptoms and/or outcomes for patients with HFrEF.

The document also addresses another common problem that isn’t always part of clinical discussions or formal documents: medication costs.

“We have to talk about it. If you choose not to, you're hobbling your patients’ ability to get the care they need,” Maddox noted. “At the end of the day, if we are patient advocates, and I think that is what we all consider ourselves, then we need to be able to think about costs and integrate that into how we talk to our patients.”

Among the cost saving strategies that can be useful for patients, the committee writes, is minimizing unnecessary duplication by better coordination of care; using generic equivalents whenever possible; working with a pharmacist, social worker or patient navigator to access Patient Assistance Programs; and requesting price matching from pharmacists.

“In addition, price-checker tools (eg, GoodRx) can be used to assist patients in locating the retailers with the lowest cost medications,” the committee writes.

Maddox concluded that despite the increasing complexities and costs of guideline-directed medical therapy for HFrEF, patients as well as their physicians and families often have more options and assistance than they may be aware of. The current document aims to be a practical means of offering up tools, ideas, and easy-to-reference clinical prompts.