Management of Worsening Heart Failure With Reduced Ejection Fraction: JACC Focus Seminar 3/3

Area of Science:

• Cardiology
• Clinical Practice Guidelines
• Heart Failure Management

Background:

• Worsening heart failure (HF) is prevalent, costly, and linked to high mortality.
• Current clinical practice guidelines lack specific recommendations for managing worsening HF.
• Recent trials show multiple therapies are safe and effective in high-risk HF populations.

Purpose of the Study:

• To propose a framework for the urgent management of worsening heart failure with reduced ejection fraction (HFrEF).
• To address the absence of dedicated clinical guidelines for this high-risk patient group.
• To outline a strategy for rapid and simultaneous initiation of evidence-based therapies.

Main Methods:

• Framework development based on current evidence for HFrEF management.
• Emphasis on treating congestion and managing precipitants of HF.
• Proposal for rapid-sequence, simultaneous initiation of quadruple medical therapy (and potentially quintuple therapy with vericiguat) in-hospital.
• Recommendation for intravenous iron administration in iron-deficient patients.

Main Results:

• The proposed framework prioritizes urgent, foundational quadruple medical therapy for HFrEF.
• It suggests considering upfront simultaneous use of vericiguat (quintuple therapy) to reduce residual risk.
• Intravenous iron is recommended for iron-deficient patients to further optimize outcomes.

Conclusions:

• A structured, urgent approach is needed for worsening HFrEF management.
• Rapid initiation of quadruple therapy, potentially including vericiguat and iron, can improve outcomes.
• This framework aims to fill the gap in dedicated clinical practice guidelines for worsening HF.