New Guidelines For The Management Of Heart Failure
Heart failure, or HF, is a prevalent chronic condition affecting over 6.2 million adults in the United States. In fact, 13.4% (379,800) of American death certificates mentioned heart failure in 2018.
Heart failure becomes more common with age, and mortality rates increase as well, resulting in the five-year mortality rate of older adults diagnosed with heart failure reaching nearly 50%.
In addition, patients discharged from the hospital after receiving heart failure treatment have a 30% mortality rate within the first year. There is a high recurrence rate, and 25% of patients are readmitted to the hospital within thirty days of being discharged. The readmission rate at six months post-discharge is at 50%.
Heart failure is also costly and is estimated to balloon to $69.7 billion by 2030 – an increase of 127%. Fortunately, there have been recent breakthroughs in heart failure treatment, thanks to effective Quadruple Therapy.
Classification By EF (Ejection Fraction)
HF with reduced EF (HFrEF) = HF with LVEF <40%
HF with mild reduced EF (HFmrEF) = HF with LVEF 41-49%
HF with preserved EF (HFpEF) = HF with LVEF >50%
HF with improved EF (HFimpEF) HF with a baseline LVEF of < 40%, a 10-point increase from baseline LVEF at a second measurement
Quadruple Therapy, according to Guideline Directed Medical Therapy (GDMT) to Reduce Morbidity and CV Mortality, consists of prescribing four medication classes together for treating heart failure.
2022 HF Guideline Directed Medical Therapy (GDMT) To Reduce Morbidity and CV Mortality
GDMT With Four Medication Classes (Quadruple Therapy)
HFrEF (reduced EF)
ARNI (i.e., sacubitril-valsartan) or ACE/ARB (i.e., Lisinopril, Losartan)
HFmrEF (mild reduced EF)
SGLT2i (i.e., empagliflozin, dapagliflozin)
HFpEF (preserved EF)*
Beta-Blocker (i.e., metoprolol, carvedilol)
HFimpEF (improved EF)
MRA (i.e., spironolactone)
*HFpEF (preserved EF) – remove beta-blocker
Reverse Remodeling With Guideline Directed Medical Therapy (GDMT)
Quadruple Therapy is very effective, offering survival and morbidity benefits as well as improvements in the quality of life for our patients. Studies have shown that the patients on GDMT have:
1. Decreased systolic BP
2. Decreased HR
3. Reduction in NT-proBNP level
4. Improvement in biventricular function, accompanied by the regression of myocardial tissue abnormalities
5. Decrease in readmission
Patients should be discharged from the hospital already with at least one agent and should be on all four agents within four to six weeks, as long as the patient tolerates medications. Do not discontinue medications after clinical improvement.
Bozkurt, B. (2022) Time to Erase Boundary Between HFrEF & HFpEF? At Least Therapeutics Suggest So!, VuMedi. Top Ten Topics in Clinical Cardiology 2022. Available at: https://www.vumedi.com/video/time-to-erase-boundary-between-hfref-hfpef-at-least-therapeutics-suggest-so/ (Accessed: February 22, 2023).
Centers for Disease Control and Prevention. Heart Failure. Available at: https://www.cdc.gov/heartdisease/heart_failure.htm (Accessed: February 22, 2023).
Januzzi, J. L., MD, FACC, FESC (n.d.). Reverse Remodeling in Heart Failure with Reduced EF: How Can We Achieve It? Available at: https://www.hkccasc.com/2020/ppt/0705%201100-1200/James%20Januzzi_Reverse%20Remodeling.pdf (Accessed: February 22, 2023).
Johnson, M., Nayak, R.K., Gilstrap, L., Dusetzina, S.B. ‘Estimation of Out-of-Pocket Costs for Guideline-Directed Medical Therapy for Heart Failure Under Medicare Part D and the Inflation Reduction Act.’ JAMA Cardiol. Published online January 11, 2023. Available at: https://jamanetwork.com/journals/jamacardiology/article-abstract/2800012?utm_campaign=articlePDF&utm_medium. doi:10.1001/jamacardio.2022.5033