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Here are the following information you must remember while generating the response. |
2) Seek context from the previous question. |
3) Do not give racist, sexist comments. Avoid such questions. |
4) If any question is out of context, tell, you only answer and comment on the context related to heart failure. |
5) HF is abbreviation of Heart Failure. |
6) You are a virtual assistant for HEART FAILURE management. |
CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction |
ABSTRACT |
In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guideli... |
The Canadian Cardiovascular Society (CCS) Heart Failure Guidelines Program provides guidance to clinicians, policymakers, and health systems as to the evidence supporting existing and emerging management of patients with heart failure (HF). Since the 2017 comprehensive update of the CCS guidelines for the management of... |
The scope of this guideline update is limited to key pharmacologic therapies for patients with HFrEF. A detailed description of nonpharmacologic management, including advance care planning, multidisciplinary care, remote monitoring, and diet and exercise prescription are not addressed. Management of important comorbidi... |
The composition and roles of the primary and secondary panels, systematic review strategy, and methods for formulating the recommendations are described at www.ccs.ca. The recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) standards. Primary panelists wer... |
STANDARD THERAPIES |
On the basis of new and emerging evidence for the pharmacologic treatment of HFrEF, updated treatment recommendations are provided herein. In the current era, patients with HFrEF should treated with 4 standard therapies, in the absence of contraindications, each representing a different class of medication with unique ... |
RECOMMENDATION |
1. We recommend that in the absence of contraindications, patients with HFrEF be treated with combination therapy including 1 evidence-based medication from each of the following categories: |
a. ARNI (or ACEI/ARB); |
b. b-blocker; |
c. MRA; and |
d. SGLT2 inhibitor. |
(Strong Recommendation; Moderate-Quality Evidence). |
Values and preferences. High value is placed on prescribing a combination of individual therapies that reduce CV mortality and HHF in well conducted randomized controlled trials. Medications such as ARNI and SGLT2 inhibitor have clinical benefits in patients treated with ACEIs or ARBs, b-blockers, and MRAs as background... |
Practical tip. The approach to initiation and titration of standard therapies should be directed by clinical and other patient factors including hemodynamic status, renal function, access to medication, adherence, anticipated side effects and tolerability, and patient preference. |
Practical tip. Every attempt should be made to titrate medications as soon as feasible after the diagnosis. It is reasonable to aim for titration of all standard therapies concurrently to target doses, or maximally tolerated doses, within 3-6 months from diagnosis. |
Practical tip. Because of the superiority of ARNI over ACEIs or ARBs in the setting of HFrEF, prescribing ARNI as first-line therapy or before full titration of ACEIs/ARBs might facilitate more rapid optimization of GDMT. |
Practical tip. If a drug with proven mortality or morbidity benefits does not appear to be tolerated (eg, low blood pressure [BP], low heart rate, or renal dysfunction), concomitant drugs (eg, diuretics) with less proven benefit should be carefully reevaluated to determine whether their dose can be reduced or the drug di... |
Practical tip. GDMT for HFrEF should be continued at the usual dose during acute intercurrent illness unless they are not tolerated or could potentially worsen severity of illness. Whenever possible, GDMT withheld during a hospitalization should be restarted before discharge. |
Practical tip. In the event of a life-threatening complication, GDMT may be discontinued abruptly, but generally, if there is concern about their use, the dose should be decreased by one-half, and the patient should be reassessed. If the dose is reduced, the previous tolerated dose should be resumed as soon as safely p... |
Practical tip. If symptomatic hypotension persists with GDMT, consider separating the administration of the dose from the timing of other medications that could also lower BP. |
RECOMMENDATION |
2. We recommend preferentially use of drugs at target doses that have been proven to be beneficial in clinical trials as optimal medical therapy. If these doses cannot be achieved, the maximally tolerated dose is acceptable |
(Table 2; Strong Recommendation; High-Quality Evidence). |
ARNI |
Registry data continue to identify suboptimal initiation and titration of goal-directed medical therapy in patients with ambulatory HF. Thus, HHF represents an ideal time to recalibrate, and optimize the treatment plan by initiating GDMT. ARNI therapy is now a well established treatment recommendation in patients with ... |
Further support for initiating ARNI as first-line HFrEF therapy in de novo or RASi-naive patients comes from the Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on Nt-Pro-Bnp in Patients Stabilized From an Acute Heart Failure Episode (PIONEER-HF) trial, and its open-label extension study. In this double-bl... |
Practical tip. In patients suitable for switching to an ARNI, an ACEI can be discontinued at the time of hospital admission enabling ARNI prescription at 36 hours after admission. A 36 hour wash-out period is not necessary for those receiving ARB therapy at the time of hospitalization. |
Practical tip. In hospitalized and ambulatory patients with HF, without previous exposure to either an ACEI or ARB, an ARNI should be considered as first-line therapy when BP and renal function/potassium levels permit. Because a washout period is needed with ACEIs, initial therapy with this class in a hospitalized patie... |
Practical tip. ARNI might reduce diuretic requirements and diuretic dosing should be carefully evaluated when starting ARNI therapy. |
Practical tip. Drug tolerability, side effects, and laboratory monitoring of ARNIs is similar to that of ACEIs or ARBs. Practical tip. Appropriate clinical and laboratory follow-up (renal function and electrolytes) is essential after discharge to monitor for adverse events. |
Practical tip. Currently, sacubitril-valsartan is the only available ARNI in Canada. Initial dosing and titration schedule should be individualized. |
RECOMMENDATION |
3. We recommend that an ARNI be used in place of an ACEI or ARB, in patients with HFrEF, who remain symptomatic despite treatment with appropriate doses of GDMT to decrease CV death, HF hospitalizations, and symptoms |
(Strong Recommendation; High-Quality Evidence). |
4. We recommend that patients admitted to hospital for acute decompensated HF with HFrEF should be switched to an ARNI, from an ACEI or ARB, when stabilized and before hospital discharge |
(Strong Recommendation; Moderate-Quality Evidence). |
5. We suggest that patients admitted to hospital with a new diagnosis of HFrEF should be treated with ARNI as first-line therapy, as an alternative to either an ACEI or ARB |
(Weak Recommendation; Moderate-Quality Evidence). |
Values and preferences. These recommendation place high value on evidence that supports the safety and efficacy of initiating ARNI therapy in hospitalized patients with or without previous RASi exposure. |
ACEIs AND ARBs |
The benefits of GDMT for patients with HFrEF, including ACEIs and ARBs, are drawn from large randomized controlled trials of ambulatory patients. Previous guideline recommendations for ACEI/ARB therapy in patients with HFrEF reflect this evidence. In contrast, recommendations regarding the role of RASi in the management ... |
ACEI/ARB initiation and continuation during HF hospitalization. ACEIs and ARBs do not have a clear role in the early management of acute or worsening HF, because there are no robust randomized controlled trial data regarding in-hospital ACEI/ARB initiation. Observational data from the Get With The Guidelines-HF Registr... |
A matched-cohort analysis of Medicare beneficiaries hospitalized for HF between 1998 and 2001 showed that patients who initiated ACEI/ARB treatment had lower 30-day readmission rates (18% vs 24%) and all-cause mortality (7% vs 14%) compared with those for whom ACEI/ARB treatment was discontinued. |
ACEIs/ARBs after acute myocardial infarction. It is well established that ACEIs should be administered to patients with impaired LVEF ( 40%) or those who have experienced HF in the early phase post myocardial infarction (MI). A systematic review of 4 trials of early ACEI initiation (0-36 hours) post ST-elevation MI in... |
ARBs as an alternative to ACEIs, in the context of ST-elevation MI, have been evaluated in 2 clinical trials. In the Optimal Trial in Myocardial Infarction With the Angiotensin II Antagonist Losartan (OPTIMAAL) trial, losartan failed to show either superiority or noninferiority compared with captopril for the primary e... |
Practical tip. ACEI intolerance describes a patient who is unable to tolerate ACEI therapy secondary to a bothersome cough (approximately 10%) or those who experience angioedema (< 1%). ARB therapy is a reasonable alternative in both of these cases, however, caution should be used in patients who develop angioedema whi... |
Practical tip. An increase in serum creatinine or decrease in estimated glomerular filtration rate (eGFR) of up to 30% in the absence of oliguria is not unexpected when an ACEI or ARB is introduced; if the increase stabilizes at 30%, there is no immediate need to decrease the drug dose but closer long-term monitoring mi... |
Practical tip. BP might fall when an ACEI or ARB is introduced, especially if introduced at a high dose or in combination with diuretic therapy. Check BP with the patient supine and standing to detect whether hypotension is present, which might suggest that a slower up-titration is warranted. |
Practical tip. Caution is warranted in patients with marginal BP; although low-dose captopril is sometimes used to initiate an ACEI in hemodynamically tenuous patients this approach has never been tested in randomized controlled trials. |
Practical tip. Longer-acting ACEIs such as perindopril or ramipril might be associated with less hypotension in patients with chronic HF, particularly in older patients. |
RECOMMENDATION |
6. We recommend an ACEI or ARB in those with ACEI intolerance, in patients with acute MI with HF or an LVEF < 40% post-MI to be used as soon as safely possible post-MI |
(Strong Recommendation; High-Quality Evidence). |
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