2021 Update to the 2017 ACC ECDP for optimization HFrEF treatment
The purpose of the update of the 2017 ECDP is to add data from emerging studies and continue to provide a practical guidance for physicians in the management of patients with HFrEF.
In 2017, the ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment, based on the 2013 AHA guidelines and the 2017 ACC/AHA/HFSA update of the 2013 guideline, was published to provide a resource for clinicians managing patients with HFrEF [1], Practical tips, tables and figures in this document explain what is needed to successfully treat patients with HFrEF. Issues addressed represent the challenge of clinical practice.
Four years later, there are new therapies added to existing therapies for the treatment of patients with HFrEF: the angiotensin receptor-neprilysin inhibitor sacubitril/valsartan, the class of sodium-glucose cotransporter-2 (SGLT2) inhibitors and percutaneous therapy for mitral regurgitation (MR). Therefore, an update to the 2017 ECDP was needed that included these new therapies into the recommendations. The authors state that this update can serve as interim guidance to clinicians while the comprehensive and definitive heart failure guideline update are awaited.
Since the 2017 ECDP publication, more data have been published supporting an expanded role for ARNI in patients with HFrEF. More specific, there is now data on use of ARNI as a de novo therapy in some patients naïve to ACEi/ARB, evidence of the effect of ARNI on patient-reported outcome measures, effect of ARNI on reverse remodeling, and that the effect of ARNI is independent of background therapy with ACEi/ARB. Also, since the 2017 publication of the ECDP, the FDA has approved a SGLT2 inhibitor for the treatment of patients with HFrEF. The DAPA-HF trial showed reduced CV death and HF hospitalization by dapagliflozin in patients with and without T2DM. In addition, the EMPEROR-Reduced trial showed a reduction of HF hospitalization and CV death by empagliflozin in patients with HFrEF with and without T2DM.
The Ten Pivotal Issues in HFrEF that are discussed in the ECDP are:
1. How to initiate, add, or switch therapies to new evidence-based guideline-directed treatments for
HFrEF.
2. How to achieve optimal therapy given multiple drugs for HF including augmented clinical assessment (e.g., imaging data, biomarkers, and filling pressures) that may trigger additional changes in guideline-directed therapy.
3. When to refer to an HF specialist.
4. How to address challenges of care coordination.
5. How to improve medication adherence.
6. What is needed in specific patient cohorts: African Americans, older adults, and the frail.
7. How to manage your patients’ costs and access to HFmedications.
8. How to manage the increasing complexity of HF.
9. How to manage common comorbidities.
10. How to integrate palliative care and the transition into hospice care.
With regard to starting guideline-directed medical therapy in a patient with a new diagnosis of HFrEF, the ECDP contains a treatment algorithm. The committee of the ECDP recommends starting either an ARNI/ACEi/ARB or beta-blocker (in some cases both). Addition of other medication is dependent on patient characteristics.
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