Implementation of the 2022 HF guidelines for equitable care

28 Apr 2023

In the American College of Cardiology (ACC) Scientific Session/World Congress of Cardiology (WCC) 2023 lecture in memory of Dr. Kanu Chatterjee, Dr. Clyde W. Yancy delivered a review on how the 2022 Heart Failure (HF) guidelines will ensure equitable care for all patients in 2023 and beyond.1 The current practice guidelines now endorse numerous novel drug- and device-based therapies for HF treatment that have demonstrated efficacy over the past 35 years.1

The primary and symptom prevention guidelines recommend continuing lifestyle modification and management strategies implemented in stage A (at the risk of HF) through stage B (pre-HF).1 For example, blood pressure is an important risk factor of HF; sodium-glucose co-transporter 2 inhibitors (SGLT2is) are recommended for patients with type 2 diabetes (T2D) and cardiovascular diseases (CVDs) or at a high risk of CVD at stage A; angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), or β-blockers (BBs) are recommended for patients with left ventricular ejection fraction (LVEF) <40% at stage B; and genetic screening and counseling are recommended for patients with cardiomyopathies at both stages.1

The 2022 guidelines firmly establish 4 pillars: angiotensin receptor-neprilysin inhibitors (ARNis), evidence-based BBs, mineralocorticoid receptor antagonists (MRAs), and SGLT2is, as the foundational standard of medical treatment for HF patients with reduced ejection fraction (HFrEF).1 The 4 pillars of guideline-directed medical therapy (GDMT) should be initiated with titration to target dosing as tolerated, labs, health status, and LVEF.1 It is suggested to continue GDMT with serial reassessment and optimization of dosing, adherence and patient education, and address care goals.1 For HF with preserved ejection fraction (HFpEF) (LVEF ≥50%), ARNi, ARB, MRA, and SGLT2i with the use of diuretics are recommended.1 In HF patients with mildly reduced ejection fraction HFmrEF (LVEF 41%-49% ), SGLT2i, ACEi, ARB, ARNi, MRA, and evidence-based BB with the use of diuretics are recommended.1 For HF with improved ejection fraction (HFimpEF), GDMT should be maintained to prevent a recurrence of HF and LV dysfunction even in asymptomatic patients.1

Dr. Yancy also introduced the progress made in improving the implementation of the 4 pillars of GDMT. 1 According to a study, treatment with quadruple therapy increased life years by 1.73 and 2.87, respectively, when compared with the triple and double therapy, highlighting the need for improved access and optimal implementation of comprehensive quadruple therapy in eligible HFrEF patients.1 The adoption of disease-modifying therapies for HFrEF has been negatively impacted by the current approach to the sequencing of drug treatments.1 If physicians prioritize the achievement of target doses of each drug class before initiating treatment with the next, it may take ≥6 months to prescribe all recommended treatments.1 A recently proposed algorithm represents one of many possibilities and can be tailored to particular circumstances: Step 1 is the simultaneous administration of a BB and an SGLT2i;  step 2 is the addition of sacubitril/valsartan 1-2 weeks after the completion of step 1; and step 3 is the addition of an MRA within 1-2 weeks of the ending of step 2.1 This outlined approach, when used on appropriate patients, can achieve all 4 pillars in 4 weeks. 1

Finally, Dr. Yancy introduced the 4 pillars of ethics to discuss how to achieve care equity in 2023 and beyond.1 HF risk assessments and multidisciplinary management strategies should target both known CVD risks and social determinants of health in order to eliminate disparities in HF outcomes in vulnerable patient populations at the risk of health disparities.1 Evidence of health disparities should be monitored and addressed at both the clinical and system levels of healthcare.1 The 4 ethics pillars are beneficence (promoting the good of others), nonmaleficence (not causing harm to patients), justice (fairness within medicine and equal distribution of resources), and autonomy (patients' right to make their own healthcare decisions).1 In conclusion, the 4 pillars of GDMT combined with the 4 pillars of ethics can help solidify the path to health equity in the implementation of HF guidelines. 1

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