Shumit/Heart-Failure-Text · Datasets at Hugging Face

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The CCS HF Guidelines Panel identiﬁed a number of unresolved questions relevant for the management of patients with HFrEF. For the purposes of this guideline update, systematic evidence reviews were limited in scope to the therapies and settings discussed herein. However, on the basis of emerging evidence, some additional considerations are worth noting, and further research will likely inform future guidelines.

1. Should ARNIs be prescribed in the setting of HF after MI?
The Prospective ARNI vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI (PARADISE-MI; NCT02924727) trial has completed enrollment and will compare sacubitril-valsartan with ramipril treatment early after high-risk MI (12 hours to 7 days) with respect to the composite end point of CV death, HHF, or urgent outpatient HF visit.

2. Should SGLT2 inhibitor treatment be initiated during an HHF episode in patients with HFrEF?
In the recently published Sotagliﬂozin on Clinical Outcomes in Hemodynamically Stable Patients With Type 2 Diabetes POST Worsening Heart Failure (SOLOIST-WHF) trial, sotagliﬂozin (a combined sodium glucose transport 1/SGLT2 inhibitor) was compared with placebo in 1222 patients with diabetes who were admitted to hospital with worsening HF. The medication was prescribed before discharge or shortly after discharge when hemodynamic stability was achieved. Sotagliﬂozin signiﬁcantly reduced the risk of achieving the primary end point of CV death, HHF, or urgent visit for HF (51.0 vs 76.3 events per 100 patient-years; HR, 0.67 [95% CI 0.52-0.85]). Ongoing trials will further evaluate the efﬁcacy and safety of initiating SGLT2 inhibitors in a spectrum of hospitalized HF patients, regardless of diabetes status (Dapagliﬂozin and Effect on Cardiovascular Events in Acute Heart Failure-Thrombolysis in Myocardial Infarction [DAPA ACT HF-TIMI 68; NCT04363697] and A Multicentre, Randomised, Double-blind, 90-day Superiority Trial to Evaluate the Effect on Clinical Beneﬁt, Safety and Tolerability of Once Daily Oral Empagliﬂozin 10 mg Compared to Placebo, Initiated in Patients Hospitalised for Acute Heart Failure [de Novo or Decompensated Chronic HF] Who Have Been Stabilised [EMPULSE; NCT04157751]) trial.

3. Do myosin activators (myotropes) have a role in managing patients with HFrEF?
Omecamtiv mecarbil (OM) is a myosin activator that enhances systolic function in patients with HFrEF by augmenting actin-myosin interaction in the sarcomere.84 In the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF), OM was compared with placebo in 8256 patients with HFrEF and worsening symptoms (either currently hospitalized or hospitalized within the past year).72 Dosing was adjusted according to study drug level, and the primary end point was a composite of HHF or urgent HF visit or CV death. Compared with placebo, OM reduced incidence of the primary outcome over 22 months of follow-up (37.0% vs 39.1%; HR, 0.92 [95% CI 0.85-0.99]). It is unclear whether there are important subgroups of patients (such as those with severely depressed LVEF) that might derive greater beneﬁt from OM. Because of the relatively modest effect of this drug compared with placebo in a high-risk HF population, and uncertainty around whether OM will receive regulatory approval in Canada, no recommendations have been made at this time.

CONCLUSION

This CCS HF guideline update heralds a shift in the clinical approach to management of patients with HFrEF and will likely have signiﬁcant practice implications. Although many areas of uncertainty remain and there is continued need for evidence to inform our approach to best practice, it is clear that knowledge translation strategies and change management will be essential to ensure that patients with HFrEF, regardless of practice setting, consistently receive the new standard for optimal medical therapy as outlined in this update.
WHAT GUIDES HEART FAILURE MEDICATION CHOICES?
Heart failure with reduced ejection fraction (HFrEF): Heart failure caused by a problem with the pumping function of the heart, called ‘reduced ejection fraction.’ If you’ve been diagnosed with heart failure with reduced ejection fraction (HFrEF), you may be wondering about your treatment options. Many medications are available to treat heart failure depending on your individual health and needs.

What is Guideline-Directed Medical Therapy?
The Canadian Cardiovascular Society (CCS) sets the standards for optimal heart failure care in Canada, known as “CCS/CHFS Heart Failure Guidelines.” In 2021, the CCS updated its treatment guidelines for people living with heart failure with reduced ejection fraction (HFrEF). These are the guidelines that your health care team follow to treat heart failure. The CCS/CHFS Heart Failure Guidelines recommend that, whenever possible, people with HFrEF be treated with 4 different medications early after their diagnosis. This combination of medications is known as “guideline-directed medical therapy.” Additional medications may also be recommended, depending on your health and risk factors. Note: The CCS/CHFS Heart Failure Guidelines were last updated in 2021. The next update may include new or additional recommendations for patients with a higher or ‘preserved’ left ventricular ejection fraction (HFpEF).

Why Optimal Medication Matters
Using all 4 guideline-directed medical therapy (GDMT) medications together could help you live 5 to 8 years longer. People who are able to take 4 GDMT medications also experience a better quality of life and fewer hospital stays than people taking fewer GDMT medications.

Challenges with Optimizing Medications
Despite clear and important benefits, studies suggest only 4 in 10 people living with heart failure are being treated with optimal medication. The reasons for this may include:

Knowledge: New research is always coming out and guidelines are updated every few years. It can be hard for health care providers and patients to stay ‘up to date’ with the latest treatment research. People with heart failure may also not fully understand their condition or how it should best be managed.

Uncertainty: Patients and/or providers may be unsure if they should change or add new medications. They may not realize the benefits of optimizing medications, or may not want to take additional pills everyday. Patients may not feel confident that their providers are up-to-date on their condition and needs.

Ability To Access Care: In Canada, most people with heart failure do not receive care from a heart failure specialist. Many face difficulties accessing care when it is needed most. GDMT requires close management by your health care provider.

Drug Costs: Not having coverage for your medications can be costly, particularly for newer medications. This can limit treatment choices.

What is Optimal Medication?
The CCS/CHFS Heart Failures Guidelines currently recommend the use of 4 different types of medications for people with HFrEF, where possible. Each of these 4 medications works in a unique way, and they work best when used together. On average, each of these medications adds an extra 1 to 2 years of life.

ARNI, ACEi, ARBs

How They Work
They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.

Commonly used drugs
ARNI: Sacubitril-valsartan (EntrestoTM)
ACEi: (“prils”) Perindopril, ramipril
ARB: (“sartans”) Candesartan, valsartan

What to watch out for
-Symptoms of low blood pressure.
-ACEi and ARNI may cause a dry cough.
-Routine bloodwork to check kidney function and potassium (risk of high potassium).

Beta Blockers

How They Work
They block adrenaline so your heart does not have to work as hard and beat as fast.

Commonly used drugs
Bisoprolol, Carvedilol, Metoprolol

What to watch out for
-Symptoms of low blood pressure or heart rate.
-You may feel tired (low energy) when you first start this medicine. This will get better as your body gets used to the medicine.
-Do not stop this medicine suddenly unless your healthcare provider tells you to. Your heart may race if you stop it suddenly.

MRAs

How They Work
They block stress hormones that make the heart stiff and cause scarring.

Commonly used drugs
Eplerenone (Inspra™), Spironolactone

What to watch out for
-Expect ongoing bloodwork for kidney function and potassium (risk of high potassium).
-Spironolactone: You may experience swelling of your breasts or tenderness. This is more common in men, and occurs in 9 out of 100 people.

SGLT2 Inhibitors

How They Work
They help lower stress on your heart.

Commonly used drugs
Dapagliflozin (Forxiga™), Empagliflozin (Jardiance™)

What to watch out for
-Genital yeast infection or bladder infection (less than 1 in 100 people). You can reduce this risk by paying close attention to your hygiene.
-Expect ongoing bloodwork for kidney function.
-This medicine is also used to treat diabetes. Other diabetes medicines may need to be adjusted when you take this medicine.

Possible Side Effects
You may experience common symptoms from taking these medications that are not serious but still noticeable. However, severe symptoms such as extreme weakness, dehydration or losing consciousness may require immediate medical attention.

Common Side Effects

ARNI, ACEi, ARBs
What to watch out for
-Symptoms of low blood pressure.
-ACEi and ARNI may cause a dry cough.
-Routine bloodwork to check kidney function and potassium (risk of high potassium).

The CCS HF Guidelines Panel identiﬁed a number of unresolved questions relevant for the management of patients with HFrEF. For the purposes of this guideline update, systematic evidence reviews were limited in scope to the therapies and settings discussed herein. However, on the basis of emerging evidence, some additional considerations are worth noting, and further research will likely inform future guidelines.

1. Should ARNIs be prescribed in the setting of HF after MI?

The Prospective ARNI vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI (PARADISE-MI; NCT02924727) trial has completed enrollment and will compare sacubitril-valsartan with ramipril treatment early after high-risk MI (12 hours to 7 days) with respect to the composite end point of CV death, HHF, or urgent outpatient HF visit.

2. Should SGLT2 inhibitor treatment be initiated during an HHF episode in patients with HFrEF?

In the recently published Sotagliﬂozin on Clinical Outcomes in Hemodynamically Stable Patients With Type 2 Diabetes POST Worsening Heart Failure (SOLOIST-WHF) trial, sotagliﬂozin (a combined sodium glucose transport 1/SGLT2 inhibitor) was compared with placebo in 1222 patients with diabetes who were admitted to hospital with worsening HF. The medication was prescribed before discharge or shortly after discharge when hemodynamic stability was achieved. Sotagliﬂozin signiﬁcantly reduced the risk of achieving the primary end point of CV death, HHF, or urgent visit for HF (51.0 vs 76.3 events per 100 patient-years; HR, 0.67 [95% CI 0.52-0.85]). Ongoing trials will further evaluate the efﬁcacy and safety of initiating SGLT2 inhibitors in a spectrum of hospitalized HF patients, regardless of diabetes status (Dapagliﬂozin and Effect on Cardiovascular Events in Acute Heart Failure-Thrombolysis in Myocardial Infarction [DAPA ACT HF-TIMI 68; NCT04363697] and A Multicentre, Randomised, Double-blind, 90-day Superiority Trial to Evaluate the Effect on Clinical Beneﬁt, Safety and Tolerability of Once Daily Oral Empagliﬂozin 10 mg Compared to Placebo, Initiated in Patients Hospitalised for Acute Heart Failure [de Novo or Decompensated Chronic HF] Who Have Been Stabilised [EMPULSE; NCT04157751]) trial.

3. Do myosin activators (myotropes) have a role in managing patients with HFrEF?

Omecamtiv mecarbil (OM) is a myosin activator that enhances systolic function in patients with HFrEF by augmenting actin-myosin interaction in the sarcomere.84 In the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF), OM was compared with placebo in 8256 patients with HFrEF and worsening symptoms (either currently hospitalized or hospitalized within the past year).72 Dosing was adjusted according to study drug level, and the primary end point was a composite of HHF or urgent HF visit or CV death. Compared with placebo, OM reduced incidence of the primary outcome over 22 months of follow-up (37.0% vs 39.1%; HR, 0.92 [95% CI 0.85-0.99]). It is unclear whether there are important subgroups of patients (such as those with severely depressed LVEF) that might derive greater beneﬁt from OM. Because of the relatively modest effect of this drug compared with placebo in a high-risk HF population, and uncertainty around whether OM will receive regulatory approval in Canada, no recommendations have been made at this time.

CONCLUSION

This CCS HF guideline update heralds a shift in the clinical approach to management of patients with HFrEF and will likely have signiﬁcant practice implications. Although many areas of uncertainty remain and there is continued need for evidence to inform our approach to best practice, it is clear that knowledge translation strategies and change management will be essential to ensure that patients with HFrEF, regardless of practice setting, consistently receive the new standard for optimal medical therapy as outlined in this update.

WHAT GUIDES HEART FAILURE MEDICATION CHOICES?

Heart failure with reduced ejection fraction (HFrEF): Heart failure caused by a problem with the pumping function of the heart, called ‘reduced ejection fraction.’ If you’ve been diagnosed with heart failure with reduced ejection fraction (HFrEF), you may be wondering about your treatment options. Many medications are available to treat heart failure depending on your individual health and needs.

What is Guideline-Directed Medical Therapy?

The Canadian Cardiovascular Society (CCS) sets the standards for optimal heart failure care in Canada, known as “CCS/CHFS Heart Failure Guidelines.” In 2021, the CCS updated its treatment guidelines for people living with heart failure with reduced ejection fraction (HFrEF). These are the guidelines that your health care team follow to treat heart failure. The CCS/CHFS Heart Failure Guidelines recommend that, whenever possible, people with HFrEF be treated with 4 different medications early after their diagnosis. This combination of medications is known as “guideline-directed medical therapy.” Additional medications may also be recommended, depending on your health and risk factors. Note: The CCS/CHFS Heart Failure Guidelines were last updated in 2021. The next update may include new or additional recommendations for patients with a higher or ‘preserved’ left ventricular ejection fraction (HFpEF).

Why Optimal Medication Matters

Using all 4 guideline-directed medical therapy (GDMT) medications together could help you live 5 to 8 years longer. People who are able to take 4 GDMT medications also experience a better quality of life and fewer hospital stays than people taking fewer GDMT medications.

Challenges with Optimizing Medications

Despite clear and important benefits, studies suggest only 4 in 10 people living with heart failure are being treated with optimal medication. The reasons for this may include:

Knowledge: New research is always coming out and guidelines are updated every few years. It can be hard for health care providers and patients to stay ‘up to date’ with the latest treatment research. People with heart failure may also not fully understand their condition or how it should best be managed.

Uncertainty: Patients and/or providers may be unsure if they should change or add new medications. They may not realize the benefits of optimizing medications, or may not want to take additional pills everyday. Patients may not feel confident that their providers are up-to-date on their condition and needs.

Ability To Access Care: In Canada, most people with heart failure do not receive care from a heart failure specialist. Many face difficulties accessing care when it is needed most. GDMT requires close management by your health care provider.

Drug Costs: Not having coverage for your medications can be costly, particularly for newer medications. This can limit treatment choices.

What is Optimal Medication?

The CCS/CHFS Heart Failures Guidelines currently recommend the use of 4 different types of medications for people with HFrEF, where possible. Each of these 4 medications works in a unique way, and they work best when used together. On average, each of these medications adds an extra 1 to 2 years of life.

ARNI, ACEi, ARBs

How They Work

They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.

Commonly used drugs

ARNI: Sacubitril-valsartan (EntrestoTM)

ACEi: (“prils”) Perindopril, ramipril

ARB: (“sartans”) Candesartan, valsartan

What to watch out for

-Symptoms of low blood pressure.

-ACEi and ARNI may cause a dry cough.

-Routine bloodwork to check kidney function and potassium (risk of high potassium).

Beta Blockers

How They Work

They block adrenaline so your heart does not have to work as hard and beat as fast.

Commonly used drugs

Bisoprolol, Carvedilol, Metoprolol

What to watch out for

-Symptoms of low blood pressure or heart rate.

-You may feel tired (low energy) when you first start this medicine. This will get better as your body gets used to the medicine.

-Do not stop this medicine suddenly unless your healthcare provider tells you to. Your heart may race if you stop it suddenly.

MRAs

How They Work

They block stress hormones that make the heart stiff and cause scarring.

Commonly used drugs

Eplerenone (Inspra™), Spironolactone

What to watch out for

-Expect ongoing bloodwork for kidney function and potassium (risk of high potassium).

-Spironolactone: You may experience swelling of your breasts or tenderness. This is more common in men, and occurs in 9 out of 100 people.

SGLT2 Inhibitors

How They Work

They help lower stress on your heart.

Commonly used drugs

Dapagliflozin (Forxiga™), Empagliflozin (Jardiance™)

What to watch out for

-Genital yeast infection or bladder infection (less than 1 in 100 people). You can reduce this risk by paying close attention to your hygiene.

-Expect ongoing bloodwork for kidney function.

-This medicine is also used to treat diabetes. Other diabetes medicines may need to be adjusted when you take this medicine.

Possible Side Effects

You may experience common symptoms from taking these medications that are not serious but still noticeable. However, severe symptoms such as extreme weakness, dehydration or losing consciousness may require immediate medical attention.

Common Side Effects

ARNI, ACEi, ARBs

What to watch out for

-Symptoms of low blood pressure.

-ACEi and ARNI may cause a dry cough.

-Routine bloodwork to check kidney function and potassium (risk of high potassium).