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CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With
Michael McDonald1, Sean Virani2, Michael Chan3
1Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
Insights
This update provides new guidelines for managing heart failure with reduced ejection fraction (HFrEF). It emphasizes incorporating novel therapies like ARNIs and SGLT2 inhibitors alongside established treatments for improved patient outcomes.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Practice Guidelines
Background:
- The Canadian Cardiovascular Society (CCS) previously updated heart failure (HF) guidelines in 2017.
- Significant new evidence has emerged since the last update, necessitating revised recommendations for HF management.
- Focus is on pharmacologic strategies for HF with reduced ejection fraction (HFrEF).
Purpose of the Study:
- To provide comprehensive, updated recommendations for the pharmacologic management of HFrEF patients.
- To integrate novel pharmacologic therapies into the standard of care for HFrEF.
- To offer practical guidance for clinicians on prescribing these therapies in various clinical settings.
Main Methods:
- Review of recent substantial evidence regarding pharmacologic therapies for HFrEF.
- Focus on novel agents including angiotensin receptor-neprilysin inhibitors (ARNIs), sinus node inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and soluble guanylate cyclase (sGC) stimulators.
- Integration of these novel therapies with established HFrEF treatments.
Main Results:
- A new standard of care for HFrEF is defined, incorporating four key drug classes: ARNIs, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors.
- Recommendations are provided for the use of additional therapies such as sinus node inhibitors, sGC stimulators, hydralazine/nitrates, and digoxin based on patient characteristics.
- Guidance is offered for applying these therapies in chronic HF, new-onset HF, and HF hospitalization contexts.
Conclusions:
- The updated guidelines establish a comprehensive pharmacologic approach for HFrEF management.
- Integration of novel agents alongside established therapies represents a significant advancement in HFrEF care.
- A holistic management strategy combining pharmacologic, non-pharmacologic, and invasive therapies is recommended post-HFrEF diagnosis.
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 guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a β-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted.
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