Expert Consensus Updates 2017 Clinical Considerations
Heart failure (HF) continues to rise alongside an aging population. The most recent statistical update from the American Heart Association notes: "An estimated 6.2 million American adults ≥20 years of age had HF between 2013 and 2016, compared with an estimated 5.7 million between 2009 and 2012." The report added approximately half of hospitalized heart failure events are characterized by reduced ejection refraction (HFrEF).
To optimize heart failure treatment, the American College of Cardiology (ACC), along with its partner the American Heart Association (AHA), published an in-depth heart failure clinical practice guideline in 2013 and produced a focused update four years later. However, since that last update, exciting new therapies for HFrEF have emerged. The ACC has just published the latest evidence-based update, including details on new drugs that have a clinically demonstrable impact on hospital readmissions, mortality and disease progression.
Thomas M. Maddox, MD, MSc, FACC, chaired the writing committee for 2021 Update to the 2017 Expert Consensus Decision Pathway for Optimization of Heart Failure: Answers to Pivotal Issues About Heart Failure with Reduced Ejection Fraction. He recently sat down with Medical News to discuss the importance of ACC guidance and new opportunities to improve patient management.
"The College is the largest professional society for cardiac care teams," said Maddox, who is an incoming American College of Cardiology Trustee and chair of the Science and Quality Committee. "Part of our mission is to provide actionable knowledge and clinical guidance to those teams to optimize cardiac care."
He continued, "The centerpieces of our clinical guidance efforts are the clinical practice guidelines, and we produce those with the American Heart Association." Maddox added the clinical practice guidelines are major undertakings with enormous literature reviews that typically come out every four to five years. "But four or five years is a long time ... so we issue interim clinical guidance, such as expert consensus decision pathways, to bridge the gap between guidelines."
The ACC has made "actionable knowledge" a priority with an emphasis on presenting guidance in a way that is easier to read, share, update and integrate into clinical practice. This clinical guidance is organized into solution sets, which bring together related activities around a specific cardiovascular condition, such as heart failure. Solutions sets include policy updates, decision support and mobile apps. Another key component of these sets are expert consensus decision pathways (ECDPs) like the one just released for HFrEF.
"The last five years has seen an explosion of new pharmaceutical targets for heart failure, which is great but dizzying if you're trying to quarterback a patient's care," said Maddox, who is a professor of medicine and executive director of the Healthcare Innovation Lab, a joint effort of BJC HealthCare and Washington University School of Medicine in St. Louis. "One of the things we try to do with these expert consensus decision pathways is make them really practical for the frontline clinician."
The hands-on information and decision flow charts can easily be translated into machine language and imported into an electronic health record. There is also a downloadable TreatHF smartphone app that puts this latest information at a clinician's .
New & Noteworthy
Maddox said the new ECDP highlights the use of two newer therapeutics for HFrEF.
"We are now recommending people use ARNIs, which are angiotensin receptor-neprilysin inhibitors," he explained. "It's a combination medicine of an ARB (angiotensin receptor blocker), which we've had for a long time, and a neprilysin inhibitor."
He said both molecules primarily exert their impact via relaxation of the relative blood pressure and improvement in the efficiency of cardiac function. "We learned that the combination of these two molecules reduced heart failure readmissions and morality by 20 percent compared to the ACE Inhibitors, which was the previous standard of care," Maddox said of clinical trial results, adding the 20 percent reduction occurred in both outcomes.
The second significant recommendation is to incorporate a sodium-glucose cotransporter-2 (SGLT2) inhibitor. "It's a molecule that blocks the kidney from absorbing both sodium and glucose," Maddox said.
The mechanism behind SGLT2 inhibitors is that patients urinate out glucose and sodium, which is why this particular therapeutic got its start in the diabetic patient population. However, clinicians also observed better heart failure control in patients with both diabetes and heart failure. Since diuretics work much the same way, perhaps seeing some improvement in HFrEF control wasn't completely surprising.
The 2019 DAPA-HF (dapagliflozin) trial focused on the benefits of the SGLT2 inhibitor vs. placebo specifically for heart failure patients. "Only about half the patients (in the trial) had diabetes, but the group that didn't have diabetes saw the same benefits," said Maddox. "This drug works on heart failure regardless of your need to control glucose." The cardiologist added, "In my mind now, this is more a heart failure drug than a diabetes drug." In May 2020, the FDA approved dapagliflozin specifically for treatment of HFrEF.
Barring a contraindication, Maddox said he couldn't see a reason not to use a SGLT2 inhibitor in HFrEF patients. "We just have such good evidence on this," he noted. Maddox added that if he had a new heart failure patient not already on a treatment regimen, in short order he would get them on a beta blocker, ARNI, aldosterone antagonist and a SGLT2.
The new ECDP also provides guidance on 10 critical issues from how to initiate, add or switch to new evidence-based therapies for HFrEF and how to address challenges of care coordination to ways to improve medication adherence and how to help patients with cost and access to medications. Maddox said the high price tag on newer therapies remains an initial barrier for many patients. However, he added, "There's a variety of strategies now to try to knock those costs down." From apps like GoodRx to financial assistance programs from manufacturers, there are a number of routes for physicians and patients to explore to ensure everyone has access to the best care.
Maddox noted this ECDP "does not supersede or take away from the clinical practice guidelines but is a bridge between guideline updates. As part of the College's mission to transform cardiovascular care and improve heart health, we need to provide the best clinical guidance possible as ongoing evidence evolves."
A Deeper Dive
To fully explore the 2021 Update to the 2017 Expert Consensus Decision Pathway for Optimization of Heart Failure, go to the Journal of the American College of Cardiology (jacc.org) and do a search for '2021 HFrEF Update' or click here.
The TreatHF app is available through both the App Store for Apple and Google Play. There is also a web version available through the American College of Cardiology site. For more information, go to the "Tools and Practice Support" tab on the ACC.org homepage and click on 'Mobile and Web Apps' to access this and other interactive tools.