Guidelines for the management of chronic heart failure

Najah Hadi, Jan Fedacko, Ram B. Singh, Galaleldin Nagib Elkilany, Osama Elmaraghi, Ehab Hamdy, Krasimira Hristova, Saibal Chakravorty, Lyudemila Shogenova, Jan Slezak, Amitabh Yaduvanshi, Meenakshi Jain, Ashok K. Shukla, Germaine Cornelissen

Research output: Chapter in Book/Report/Conference proceedingChapter

Abstract

As given in previous chapters, the pathophysiology of heart failure (HF) indicates that behavioral factors predisposing HF are not duly treated before the initiation of drug therapy. For treatment of HF, pharmacotherapy and lifestyle recommendations have been suggested by all the agencies concerned with health and diseases. These guidelines have been updated in light of recent developments across the spectrum of left ventricular ejection fraction. The most interesting areas across these guidelines include recommendations on quadruple therapy for patients with HF with reduced ejection fraction (HFrEF). It seems that there is no guideline proposed for the ideal sequence of initiation of therapy, such as treatment of anemia via intravenous iron among patients with HFrEF and simultaneous deficiency of iron. The guidelines are unanimous in recommending the combination of four standard therapy options for the treatment of HFrEF. These are angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), or angiotensin receptor-neprilysin inhibitors (ARNI); beta-blockers; mineralocorticoid receptor antagonists (MRA); and sodium-glucose cotransporter-2 inhibitors (SGLT2i). The Canadian guidelines do, however, recommend that ACEI/ARB be switched to ARNI prior to discharge in patients hospitalized with acute decompensated HF and that ARNI be started in patients admitted with a new HFrEF diagnosis. These guidelines also advise that starting with an ARNI rather than an ACEI/ARB may lead to more rapid optimization of therapy. Meanwhile, the ESC advises that ARNI “may be considered as a first-line therapy instead of [ACEI]” without further specification of which conditions may warrant de novo initiation. In view of the lower-quality evidence, there are disagreements regarding the management of HF with preserved ejection fraction (HFpEF) and uncertainty regarding the management of HF with mildly reduced ejection fraction (HFmrEF). Such uncertainty may be due to the etiology of HF because HF in patients with coronary artery diseases (CAD), in particular acute myocardial infarction (AMI), may have different strategies. Novel mechanisms have been proposed to explain the benefits of drug therapy, including improved cardiomyocyte calcium handling, enhanced myocardial energetics, induced autophagy, and reduced epicardial fat, which can occur via lifestyle modification and SGLT2 inhibitors. In addition, there are opportunities for improvement in guidelines and harmonization. It seems that there is broad agreement across these guidelines, although some areas of controversy remain and need new trials.

Original languageEnglish (US)
Title of host publicationPathophysiology, Risk Factors, and Management of Chronic Heart Failure
PublisherElsevier
Pages325-341
Number of pages17
ISBN (Electronic)9780128229729
ISBN (Print)9780128231111
DOIs
StatePublished - Jan 1 2024

Bibliographical note

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© 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Keywords

  • Acute heart failure
  • cardiac failure
  • cardiomyocyte damage
  • drug therapy

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