3.3 Management of Heart Failure (with Reduced Ejection Fraction)

Robi Islam; John Smithson; Shane MacDonald; Karl McDermott

3.3 Management of Heart Failure (with Reduced Ejection Fraction)

Therapeutic Objectives

Heart failure is treated with the aims to:

Relieve symptoms
Improve quality of life
Slow disease progression
Prevent acute exacerbations / hospitalisation
Prolong active life.

Principles of Heart Failure Management

Non-Pharmacological Management

Non-pharmacological treatment strategies are an essential consideration. These are as important as pharmacological treatment for heart failure.

Pharmacological Management

Key Takeaways

4 main drug classes are used in combination for the treatment of heart failure with reduced ejection fraction (HFrEF). These are commonly referred to as the ‘4 pillars of HF management‘.

Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin-Receptor Blockers (ARBs) *
Aldosterone antagonists
Beta-blockers (HF-specific)
Sodium-glucose cotransporter 2 (SGLT2) inhibitors

* Note: ACEI/ARB can be swapped out for an Angiotensin-Receptor Neprilysin Inhibitor (ARNI). However, the ARNI is only PBS-subsidised for use as a second line agent instead of an ACEI or ARB, in patients who have persistent symptoms despite initial treatment with an ACEI or ARB and beta blocker (+/- the aldosterone antagonist).

All of the above drug classes have been shown to improve mortality and other outcomes in HFrEF.

Drugs that improve outcomes in heart failure with reduced ejection fraction (HFrEF) include angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), beta

blockers, aldosterone antagonists, and SGLT2 inhibitors.

We also have another class that is an angiotensin-receptor neprilysin inhibitor (ARNI). There is only one combination drug in this class, sacubitril with valsartan, brand name (Entresto(R)). According to current consensus guidelines, the ARNI may be started first line, without the need to transition from an ACEI or ARB. However, this is not often seen in practice, because of current PBS restrictions, to reduce the cost to the patient. At the time of writing, this ARNI is only PBS-subsidised as a second-line agent to be used in place of the ACEI or ARB if the patient was trialled on an ACEI or ARB and a beta blocker for a period of time with persistent symptoms despite this. It is essential that if the ARNI is started, the ACEI or ARB is ceased. And if swapping from an ACEI to the ARNI, there must be a 36-hour washout period.

Combination drug therapy with use of all 4 pillars (i.e., an ACEI or ARB or ARNI, plus a beta blocker, plus an aldosterone antagonist, plus an SGLT2 inhibitor), improves prognosis and controls symptoms of HFrEF better than use of any 1 drug class alone.

A Snippet of Current Guidelines

This is the current standard of care for every patient with heart failure with reduced ejection fraction (HFrEF) irrespective of disease severity.

Source: National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand. Consensus Statement on the Current Pharmacological Prevention and Management of Heart Failure

Already you can see that management of HfrEF is divided down the middle. It is split depending on whether the patient presents with overt signs and symptoms congestion or without any signs and symptoms of congestion (in which case they would be considered euvolaemic or ‘not fluid overloaded’). The main difference between the 2 is that beta blockers aren’t started if the patient is congested at the time of their diagnosis (beta blockers aren’t started until the patient is euvolaemic).

You can also see diuretics on the left spanning vertically across every row alongside the non-pharmacological recommendations. So, diuretics can be used whenever needed to help to manage congestion, on top of other maintenance therapies outlined in this figure.

You can see a strong recommendation for use of the 4 pillars at the top of this figure in the green box.

Then we up-titrate the doses of these heart failure therapies according to tolerability.

Later line treatment options are also suggested in these guidelines.

Dose Titrations

As a general rule, doses of all agents used for heart failure are started at a low dose and gradually titrated upwards (~ every 2-4 weeks) according to tolerability to the maximum recommended dose.

If adverse effects (e.g., low blood pressure, declining renal function, or rising potassium) are problematic, then is better to have low doses of most/all of the pillars than it is to have a high dose of only one pillar.

Nurse-practitioner (NP)- led medication titration clinics:

Nurse practitioners can optimise heart failure medication doses according to a cardiologist-initiated medication titration plan (see example here).

Dose titration occurs only if it is clinically appropriate based on the nurse’s assessment of the patient at the time of their appointment (taking into account patient observations including blood pressure, heart rate, and relevant blood results).

With regards to duration of drug therapy in heart failure with reduced ejection fraction:

If the ejection fraction recovers, the current recommendation is for neurohormonal antagonists (ACEI/ARB/or ARNI, and MRA, and beta blocker) to be continued long-term at target doses, unless the reversible cause of the heart failure has been identified and corrected.

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