Societies release guideline update for heart failure therapies

In a guideline update published today, the American College of Cardiology, the American Heart Association and the Heart Failure Society of America detail the groups' recommendations for the use of two new heart failure medications.

This update to the 2013 ACCF/AHA Guideline for the Management of Heart Failure includes the addition of an angiotensin receptor-neprilysin inhibitor (ARNI) (valsartan/sacubitril), and a sinoatrial node modulator (ivabradine) to the list of treatment options for Stage C heart failure patients with a reduced ejection fraction. The previously determined drug options for these patients include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), aldosterone antagonists, beta blockers, the combination of isosorbide dinitrate and hydralazine and diuretics. The goal of all of these medications is to relax blood vessels, reduce (biological) stress and improve the function of the heart.

"Not every patient is a good candidate for every drug; these guidelines can help physicians decide who best fits which treatment," said Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA, professor of medicine and chief of cardiology at the Northwestern University Feinberg School of Medicine and chair of the writing committee. "This document details the benefits and risks of these new therapies so that patients at high risk can be directed towards alternative therapies."

According to the new recommendations, a therapeutic regimen of an ACE inhibitor or ARB or ARNI along with a beta blocker and an aldosterone antagonist is the new recommended therapy for patients with chronic symptomatic heart failure with reduced ejection fraction. ARNIs should replace ACE inhibitors (or ARBs) when stable patients with mild-to-moderate heart failure on these therapies have an adequate blood pressure and are otherwise tolerating standard therapies well. ARNIs, however, should not be used with an ACE inhibitor and should not be used by patients with a history of angioedema.

Ivabradine may be beneficial in reducing heart failure hospitalizations in patients with symptomatic stable chronic heart failure with reduced ejection fraction who are receiving guideline-directed evaluation and management, including a beta blocker at a maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 beats per minute or greater at rest.

"Treatment options for patients with heart failure have expanded considerably. There is more hope than ever before for patients with heart failure. These guideline recommendations will serve as a tool to guide the choice of therapy and in turn improve outcomes," said Mariell Jessup, MD, FACC, FAHA, professor of medicine at the University of Pennsylvania School of Medicine and vice chair of the writing committee.

While a full update to the heart failure guideline is being developed, these recommendations are being released early to coincide with the release of the 2016 European Society of Cardiology Guideline on the Diagnosis and Treatment of Acute and Chronic Heart Failure. The recommendations are being released concurrently in order to minimize confusion and improve the care of patients with heart failure.