Implementation of treatment for patients with HFrEF is poor, despite recommendations in guidelines and evidence from large-scale randomized clinical trials. Most patients do not receive treatment with all drugs or only at below target doses, and most of them do not receive recommended devices. Barriers consist of tolerability issues, limited access to specialists, physician inertia, organization of care, poor socioeconomic status, lack of social support, and poor medication adherence.
Over the last few years, new treatment options for HFrEF have evolved. Instead of only dealing with ACEi, ARB, betablockers, MRA, digoxin, diuretics and devices, novel drug therapies have arrived with proven benefit in patients with HFrEF. These include ivabradine, sacubitril/valsartan, SGLT2i, ferric carboxymaltose, vericiguat and omecamtiv mecarbil. This has increased the complexity of management of HFrEF patients, together with the complex implementation and uptitration of guideline-directed medical therapy. Also, HF patients are often elderly with comorbidities for which they also have to take multiple drugs.
All this has led to a consensus document to identify patient profiles that may be relevant for treatment implementation in patients with HFrEF. After applying inclusion and exclusion criteria of RCTs, subgroup analyses and meta-analyses, and taking into consideration specific profiles that may limit the implementation of medical therapy, nine profiles for personalized specific treatment options were listed.
- Profile 1: Patients with low blood pressure and high heart rate
- Profile 2: Patients with low blood pressure and low heart rate
- Profile 3: Patients with normal blood pressure and low heart rate
- Profile 4: Patient with normal blood pressure and high heart rate
- Profile 5: Patients with atrial fibrillation and normal blood pressure
- Profile 6: Patients with atrial fibrillation and low blood pressure
- Profile 7: Patients with chronic kidney disease
- Profile 8: Pre-discharge patient
- Profile 9: Patient with hypertension despite guideline-directed medical therapy
The authors write: “A personalized patient approach, adjusting guideline-directed medical therapy to the patient's haemodynamic profile (blood pressure, heart rate, congestion) and kidney function, may allow to achieve a better and more comprehensive therapy for each individual patient better than the more traditional hierarchical, step by step, standardized forced titration of each drug class before initiating treatment with the next, in a misguided ‘one size fits all’ approach.”