Overview
This lecture reviews the evidence-based therapeutic algorithm for managing heart failure with reduced ejection fraction, highlighting stepwise pharmacological treatment, monitoring, and referral criteria for Canadian primary care physicians.
Importance of Heart Failure Management
- Heart failure has a higher mortality risk than several cancers.
- Most Canadian heart failure patients are managed by primary care physicians.
- Evidence-based management improves outcomes in heart failure with reduced ejection fraction.
2017 CCS Heart Failure Guidelines & Algorithm
- The 2017 Canadian guidelines offer updated recommendations integrating the last decade of research.
- The therapeutic algorithm has three main steps focused on medication titration and assessment.
Step 1: Initiate Standard Triple Therapy
- Triple therapy includes an ACE inhibitor, beta blocker, and mineralocorticoid receptor antagonist (MRA).
- Substitute an ARB for ACE if ACE is not tolerated.
- Titrate all medications to maximally tolerated or target doses within 4–6 months.
- Regular follow-up is required; stable patients may be seen every 6–12 months.
- Repeat echocardiography 3 months after completing titration.
Step 2: For Symptomatic Patients (NYHA Class II or Higher)
- If symptoms persist, add Evabradine for patients with sinus rhythm and heart rate ≥70 bpm.
- Consider switching ACE/ARB to an ARNI (Secubitril Valsartan), unless contraindicated.
- Evabradine is an add-on, not a replacement for beta blockers.
- A 36-hour washout is required when switching from ACE to ARNI; not needed from ARB.
- Monitor potassium, renal function, and blood pressure due to ARNI side effects.
Step 3: Advanced Therapy and Referral
- Reassess symptoms and ejection fraction after medication changes.
- NYHA Class I: Reassess every 1–3 years if stable.
- NYHA Class I–III with LVEF ≤35% after 3 months: Refer for device therapy.
- NYHA Class IV: Refer to a cardiologist or heart failure clinic.
Additional Management Considerations
- Treat underlying causes (e.g., ischemia, hypertension, valvular disease).
- Use lowest effective diuretic dose to maintain fluid balance.
- Manage lifestyle: exercise, salt and fluid intake, daily weight, immunizations, and self-care education.
- Multidisciplinary teams improve outcomes.
Key Terms & Definitions
- Reduced Ejection Fraction (HFrEF) — Heart failure with decreased ability of the heart to pump blood (LVEF ≤40%).
- Triple Therapy — Combination of ACE inhibitor (or ARB), beta blocker, and MRA.
- ARNI — Angiotensin receptor neprilysin inhibitor (e.g., Secubitril Valsartan).
- NYHA Classification — Grading of heart failure symptoms from I (asymptomatic) to IV (severe).
- Evabradine — Heart rate-lowering agent for symptomatic patients in sinus rhythm with high heart rate.
Action Items / Next Steps
- Prescribe and titrate heart failure medications per guideline algorithm.
- Monitor patients and reassess symptoms and LVEF regularly.
- Refer to a cardiologist or heart failure clinic as indicated.
- Review full CCS heart failure guidelines as needed.