Practice Update: Cardiology

HEART FAILURE & TRANSPLANTATION 18

Update on the management of heart failure from the ACC/AHA/HFSA JACC: Journal of the American College of Cardiology Take-home message

This focused update represents the second part of a 2-stage publication; with the first part having been published as the “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Ther- apy for Heart Failure”, which introduced guidance on new therapies, specifically for the use of an angiotensin receptor–neprilysin inhibitor (ARNI) (valsartan/sacubitril) and a sinoatrial node mod- ulator (ivabradine). That focused update was published concurrently with the European Soci- ety of Cardiology’s complete guideline, “2016 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure.” 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the AmericanCollege of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Car- diol 2017 Apr 21;[EPub Ahead of Print], CW Yancy, M Jessup, B Bozkurt, et al.

• This is a 2017 focused update to the 2013 ACCF/AHA guidelines on management of heart failure. This report is the result of collaboration between American College of Cardiology, the American Heart Association, and the Heart Failure Society of America. • The authors address use of newer biomarkers, new pharmacotherapies for heart failure, and management of specific comorbidities that frequently coexist with heart failure.

guidance on the management of HF. The scope of the focused update includes revision to the sections on biomarkers; new ther- apies indicated for stage C HF with reduced ejection fraction (HFrEF); updates on HF with preserved ejection fraction (HFpEF); new data on important comorbidities, including sleep apnea, anemia, and hypertension; and new insights into the prevention of HF.

Abstract The purpose of this focused update is to update the “2013 ACCF/AHA Guideline for the Man- agement of Heart Failure” (2013 HF guideline) in areas in which new evidence has emerged since its publication. For this update and future heart failure (HF) guidelines, the Heart Fail- ure Society of America (HFSA) has partnered with the ACC and AHA to provide coordinated

COMMENT By Clyde W Yancy MD, MSc, MACC, FAHA, MACP, FHFSA N ew heart failure guidelines are out, and we should be all in. These are not only clinical practice guidelines, but also potentially practice-changing recommendations based on the very highest tiers of evidence capable of changing patient outcomes. Here’s what’s new and worth your immedi- ate consideration: 1. TREATMENT : The use of the latest indicated therapies for reduced ejection fraction heart failure (HFrEF) – valsartan/ sacubitril and ivabradine – is once again endorsed. A new treatment algorithm now enables optimal implementation. 2. PROGNOSTICATION : The use of biomarkers has been consist- ently endorsed to support the diagnosis of heart failure, but that use is extended now to gauge recurrent heart failure admission, disease severity, and mortality. 3. COMORBIDITIES : The prior 2013 guideline addressed heart fail- ure with atrial fibrillation, coronary artery disease, and valvular heart disease; the updated list of comorbidities in heart failure now includes anemia, sleep-disordered breathing, and hyper- tension. Now we have evidence that informs exactly how we should approach these important comorbidities. If you are not certain about when and how to treat anemia in heart fail- ure; when and to whom we should prescribe CPAP and for what expected outcome; and what is the recommended tar- get pressure for heart failure with hypertension, then review this new guideline. It should be immensely helpful. 4. HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFpEF) : After very careful review and in light of the complete body of available evidence, this guideline has, for the first time, supported an indicated therapy for HFpEF with important provisos and with a very measured strength of recommendation. Short version: If your patient with HFpEF has a profile similar to the “Americas” population in TOPCAT,

this guideline would prompt, with some trepidation, the use of an aldosterone antagonist. This will undoubtedly need to be refereed via a shared decision-making discussion with our patients; but, finally, a treatment has emerged and is endorsed by a clinical practice guideline. 5. PREVENTION : Once a patient has symptomatic heart failure, even when treated with the best interventions, the long-term prognosis, albeit improved, remains guarded. Without ques- tion, it is highly preferable to avoid that first symptom. This guideline endorses the prevention of heart failure in two impor- tant ways – it is reasonable to use biomarker screening looking for only modest elevations that are still within the range of nor- mal – in those with positive risk factors for CVD and consider early administration of RAAS inhibition while those patients remain asymptomatic. More importantly, the SPRINT data are persuasive; in those persons with hypertension and who are at risk for CVD, an aggressive treatment target, ie, <130/80, is associated with a marked reduction of nearly 40% in the onset of heart failure. This is no small issue; avoiding the first symptom of heart failure by targeting a common risk factor for CVD may in fact lead to a reduction in the incidence of a disease which remains with important and sometimes dire con- sequences. As much as we celebrate our therapeutic triumphs, we should perhaps think about our quiet win – prevention. In my office is a simple plaque quoting a Chinese proverb, “a mediocre physician treats end-stage disease; a good physician treats disease; a great physician prevents disease.” We should all aspire to be great heart failure physicians.

Dr Yancy is Chief of Cardiology at Northwestern University, Feinberg School of Medicine and Associate Director of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital in Chicago.

PRACTICEUPDATE CARDIOLOGY