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Minimization or withdrawal of oral pharmacotherapy in chronic heart failure patients with improved myocardial
Yuxiang Luo1,2, Wenbin Xiao3, Yusuf Z Sener1
1Thoraxcenter, Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands.
Insights
For patients with improved heart function, evidence suggests withdrawing loop diuretics or using carvedilol alone may be safe. However, stopping other heart failure medications is not recommended. More research is needed.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Chronic heart failure (HF) management often involves lifelong polypharmacy.
- The necessity of continuing multiple medications in patients with improved cardiac function is debated.
- Optimizing pharmacotherapy in HF is crucial for patient outcomes and resource allocation.
Purpose of the Study:
- To systematically review the current literature on minimizing or withdrawing pharmacotherapy in chronic heart failure patients with improved myocardial function.
- To synthesize evidence regarding the safety and efficacy of reducing medication regimens in this patient population.
Main Methods:
- A systematic literature search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials.
- Seven studies (n=552) involving pharmacotherapy minimization or withdrawal in chronic HF patients with improved ejection fraction or stable NYHA status were included.
- Heterogeneity in study design and protocols was noted, influencing the interpretation of findings.
Main Results:
- Loop diuretic withdrawal showed some support from one non-randomized study and one RCT.
- Minimization of angiotensin receptor-neprilysin inhibitors or withdrawal of mineralocorticoid receptor antagonists (MRA) was not favorable.
- Carvedilol monotherapy was favored in one small RCT; however, high relapse rates were observed after multiple drug withdrawal in some patient groups, with a significant need for re-initiation of drugs due to cardiac comorbidities.
Conclusions:
- Evidence for minimizing or withdrawing oral pharmacotherapy in chronic HF patients with improved function is limited and heterogeneous.
- Loop diuretic withdrawal and possibly carvedilol monotherapy are supported, but not the withdrawal/minimization of renin-angiotensin system inhibitors or MRA.
- Large randomized controlled trials (RCTs) are essential to establish appropriate treatment strategies for de-escalating HF pharmacotherapy.
Aims:
The necessity of lifelong treatment and polypharmacy in chronic heart failure (HF) patients with improved myocardial function remains debated. This systematic review aims to synthesize current literature regarding this issue.
Methods And Results:
A systematic literature search was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from the inception to 18 October 2024. Seven studies (n = 552) reporting minimization or withdrawal of pharmacotherapy in chronic HF patients with improved ejection fraction or stable New York Heart Association status were included. Findings were heterogeneous due to variations in study design and protocols. Loop diuretic withdrawal was favoured by one non-randomized study (n = 26) and one randomized controlled trial (RCT) (n = 188). Minimization of angiotensin receptor-neprilysin inhibitors (n = 77) or withdrawal of mineralocorticoid receptor antagonists (MRA) (n = 70) was not favourable. Carvedilol monotherapy was favoured by one small-sample RCT (n = 60). One RCT (n = 51) reported a high overall relapse rate (65%) following multiple drug withdrawal in recovered patients with dilated cardiomyopathy. Another RCT (n = 80) found a low occurrence of cardiac dimensional deterioration (7.5%) following multiple drug withdrawal in post-cardiac resynchronization therapy patients with normalized ejection fraction. However, 28% required drug re-initiation due to cardiac comorbidities.
Conclusion:
The existing evidence on minimizing or withdrawing oral pharmacotherapy in chronic HF patients with improved myocardial function remains very limited and heterogeneous, supporting only loop diuretic withdrawal and possibly carvedilol monotherapy, but not the minimization or withdrawal of renin-angiotensin system inhibitors, MRA, or the combination of HF medications. Large RCTs are needed to determine the appropriate treatment strategy.
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