Deciding on an Initial Treatment for Heart Failure

James Januzzi, MD: You’ve heard now folks about early recognition and initiation of treatment with effective therapies to prevent heart failure, and later referral at the time that a patient might need an advanced heart failure specialist. Now, let me ask Dr Butler. Our colleagues have mentioned that we have effective treatments, and there’s a lot of overlap between prevention as well as the treatment of heart failure. Can you give us a sense of what factors are considered when deciding on an initial treatment approach? How do we think about stratifying treatment for our patients?

Javed Butler, MD: That field has evolved quite a lot, and it continues to evolve. We had a few things we used to say up until recently, that there are no treatments that alter the course of acute heart failure or patients who are hospitalized. We have no therapy for heart failure with preserved ejection fraction. We don’t have any therapies for heart failure with midrange ejection fraction. All we have are devices and drugs that are very beneficial in patients with heart failure and reduced ejection fraction. But we had these strict recommendations based on historical construct that you give first medication A, go up on the dose, go up on the dose, bring back, give medication B, and all those kinds of stuff. That field is really evolving.

I think where we are right now is that we have 4 therapies that are known to improve outcomes of patients with heart failure and reduced ejection fraction, RAS [renin-angiotensin system] inhibitor, neprilysin inhibitor, β-blocker, MRAs [mineralocorticoid receptor antagonists], and SGLT2 [sodium-glucose cotransporter-2] inhibitor, that really in the absence of contraindications should be given to the patients. And the factors that come into play are usually common things, blood pressure, tolerability, electrolyte abnormalities, hyperkalemia, renal function, and you can individualize it. You can use either this drug and some of these drugs actually enable each other. SGLT2 inhibitors may actually enable the use of an MRA because they lower the risk of hyperkalemia. You can use your best clinical judgment, but this quadruple therapy, as soon as we can, is really important. Then, there is enough evidence that is accumulated based on secondary analysis, that it’s not just a therapy for ejection fraction less than 40%, but even all the way up to 50%, patients tend to benefit.

We now have a positive trial in patients with heart failure with preserved ejection fraction also, although this just came out about a couple of weeks ago, so it will take some time by the time it goes through the regulatory approval process and the guidelines. And then finally, most of these therapies that I’m talking about, when we have tried using them in the hospital setting in patients with acute heart failure, either earlier during hospitalization or at least at the time of discharge, are associated with improvement in outcomes in the long run also. I think the guidelines are becoming simpler: give these therapies, individualize it to the patient, give it in outpatient setting, give it in the inpatient setting. The biggest thing is let’s not have the inertia and just put everything in the back burner but go ahead and provide patients the best medical therapy.

James Januzzi, MD: That’s great, Javed. And it’s such an important message. All 4 of us participated in an expert consensus decision pathway document that the American College of Cardiology published on the management of heart failure. There was a statement in the document that I think is so chilling, which is waiting to initiate guideline-directed medical therapy is associated with never initiating guideline-directed medical therapy. Thus, it’s important to identify your moments for intervention. Hospitalization is a clear opportunity to initiate low doses of each of the pivotal therapies, which we are now going to talk about, and set the stage for the outpatient treatment of patients.

This transcript has been edited for clarity.