Put Heart Failure Guidelines in Perspective

Big changes in guidelines will lead to debate about managing heart failure with reduced ejection fraction (HFrEF).

We're used to "triple therapy" for HFrEF...an ACEI or ARB, an evidence-based beta-blocker (carvedilol, etc), and an aldosterone antagonist (spironolactone, etc)...to reduce hospitalizations and death.

Now Entresto (sacubitril/valsartan) is preferred INSTEAD of an ACEI or ARB when possible...since it prevents hospitalization or CV death in about 1 in 21 patients versus an ACEI.

Guidelines also suggest "QUAD therapy"...adding an SGLT2 inhibitor (Forxiga, etc) to triple therapy, regardless of diabetes. This prevents hospitalization or CV death in about 1 in 20 patients.

But med adherence in clinical trials is much higher than in real-world patients. Plus Entresto costs about $240/month...or an SGLT2 inhibitor about $90/month.

Consider whether this new guidance is practical for your patient.

Continue to focus on optimizing traditional triple therapy first...this can cost under $30/month. And less than 1% of patients with HFrEF are on triple therapy at target doses.

If patients still have heart failure symptoms, suggest switching from an ACEI or ARB to Entresto. But point out that Entresto is taken bid...and causes low BP in 1 in 21 patients.

Educate patients to wait at least 36 hours after stopping an ACEI if switching to Entresto...to reduce the risk of angioedema.

If symptomatic patients are already on optimized triple therapy with Entresto...or also have type 2 diabetes...suggest adding an SGLT2 inhibitor. Benefits are likely a class effect.

But weigh SGLT2 inhibitor downsides...genitourinary infections, dehydration, etc. Consider lowering diuretic doses when starting due to risk of hypovolemia and acute kidney injury.

If cost is an issue, consider ways to help patients afford their meds...such as whittling duplicate or unneeded meds.

See our resource, Improving Heart Failure Care, for patient education tools, strategies to improve adherence, and more.

Key References

  • Can J Cardiol. 2021 Apr;37(4):531-546
  • J Am Coll Cardiol. 2022 Mar 24. doi: 10.1016/j.jacc.2021.12.012
  • N Engl J Med. 2020 Oct 8;383(15):1413-1424
  • N Engl J Med. 2014 Sep 11;371(11):993-1004
  • N Engl J Med. 2019 Nov 21;381(21):1995-2008
  • Can Fam Physician. 2021 Dec;67(12):915-922 (4-28-22)
Pharmacist's Letter Canada. May 2022, No. 380514



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