ACC Updates HFrEF Decision Pathway, Reinforcing the Four Pillars of Therapy

The American College of Cardiology (ACC) has updated its expert consensus decision pathway for the treatment of patients who have heart failure with reduced ejection fraction (HFrEF), providing updates on medication choice and underscoring the importance of the four pillars of guideline-directed medical therapy (GDMT).

Since the prior update to the decision pathway was released in 2021, the ACC, the American Heart Association, and the Heart Failure Society of America together issued a full HF guideline update, in which there was an emphasis on getting patients with HFrEF on four key classes of medical therapy—an angiotensin receptor-neprilysin inhibitor (ARNI), a beta-blocker, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter 2 (SGLT2) inhibitor.

Thus, there was a need to revamp the decision pathway to reflect those changes as well as additional trial data, Thomas Maddox, MD (Washington University School of Medicine in St. Louis, MO), chair of the writing committee for the document’s latest iteration, told TCTMD.

The new decision pathway, published online Friday in the Journal of the American College of Cardiology, is “a way for the college to take sometimes very large and somewhat dense clinical guidelines and, if you will, simplify it for the clinician and make sure that it is really focused on the practical points that frontline clinicians need to manage whatever condition—in this particular case, it’s heart failure,” Maddox said.

He added: “These kinds of policy documents are complements, not competitors or replacements, for clinical guidelines.”

Easy-to-Navigate Advice

Like the 2021 version, the new pathway provides advice around 10 key issues in heart failure, including initiating, adding, or switching to GDMT; optimizing therapy in the context of multiple drug classes; referral to an HF specialist; care coordination; medication adherence; care of specific patient cohorts; and how to handle the increasing complexity of HF management, common comorbidities, and the integration of palliative care and the transition to hospice care. Navigation of the document is eased by the inclusion of algorithms and tables, which have been updated to reflect the latest evidence.

According to Maddox, there are three main changes to the decision pathway. First, the authors give a preference for initiating therapy with sacubitril/valsartan (Entresto; Novartis) rather than an ACE inhibitor or ARB, whereas previously all three had been considered roughly equivalent. “Now, it’s pretty clear that Entresto is superior in reducing both heart failure hospitalization and death,” Maddox said, noting that an ACE inhibitor or ARB is still an acceptable option if patients have problems with side effects or cost with the ARNI.

The document also underscores the strength of the data backing the use SGLT2 and SGLT1/2 inhibitors in patients with HFrEF, placing these agents as one of the four pillars of GDMT.

The third major change is a stronger emphasis on getting patients with HFrEF on all four of those classes of evidence-based GDMT, barring contraindications. “We know that in combination, those four meds provide the best benefit in terms of reducing symptoms, hospitalizations, and death, and we’re recommending that if somebody is newly diagnosed that we proceed with all due speed to get them on all four and ideally do it within 3 months,” Maddox said. “That degree of comprehensiveness of medication and rapidity of getting them on it is something that we really tried to reinforce.”

There are, however, some obstacles to that strategy, including potential side effects and issues around cost and the systems of care set up to manage patients with HFrEF, Maddox said. He noted that the decision pathway provides guidance on minimizing the impact of side effects as well as responding to cost concerns that limit access to recommended medications.

Maddox said that growing use of telehealth and remote monitoring technologies may help ease some of the burden of getting patients started on multiple classes of medication quickly by reducing the number of times they’re required to come into the office.

“Although it’s still being sorted out about how do clinicians fit that into their workflow, how do they get paid for those kinds of encounters, I do think those are going to be promising strategies to make a system for initiating and monitoring these medicines a little bit more palatable to a patient and their life,” he said.

More work is needed also to determine how best to construct care teams to support patients, Maddox added.

“We’ve realized that the omniscient doctor is kind of a myth and that the skills that are needed actually are going to take a team,” he said. “We need social work, we need palliative care, we need pharmacists, we need advanced practice providers, in addition to the MDs and DOs. How those teams are structured, how they work together effectively, and how they interact with a patient I think needs further research.”