Despite advances in medical therapy, the risk of mortality is higher in patients with heart failure than it is in some common cancers. Most patients with heart failure in Canada are managed by a primary care physician. It is therefore important to monitor their health and their health conditions. for primary care physicians to apply an evidence-based approach to the management of patients with symptoms of heart failure and a reduced ejection fraction. The 2017 heart failure guideline update was published in the November 2017 issue of the Canadian Journal of Cardiology and is a comprehensive set of recommendations that integrates and updates the last 10 years of CCS heart failure guidelines.
This algorithm outlines all of the essential steps for applying guideline-directed medical therapy in patients with heart failure with reduced ejection fraction. We've divided this therapeutic algorithm into three main steps. Let's take a closer look at each step in the algorithm.
The first step is to initiate standard triple therapy. This consists of an angiotensin-converting enzyme inhibitor, or ACE, plus a beta blocker, plus a mineralocorticoid receptor antagonist, or MRA. Patients who cannot tolerate an ACE can receive an angiotensin receptor blocker, or ARB, instead.
ACEs, ARBs, beta blockers, and MRAs have all been shown in landmark clinical trials to independently reduce the risk of mortality in patients with heart failure with reduced ejection fraction. According to most Canadian heart failure experts, the entire triple therapy titration to maximal tolerated or target doses should be completed within 4 to 6 months for most patients. Once standard triple therapy has been initiated and optimized, the patient should be followed up regularly to monitor their response to therapy and tolerability of medications. The optimal frequency of clinical follow-up has not been definitively established. The CCS's Heart Failure Companion suggests that low-risk patients can be seen every 6 to 12 months.
Patients who are not stable or who are in the process of optimization should be seen more frequently. Repeat echocardiography should generally be obtained 3 months after completion of triple therapy titration. The next step depends on the severity of heart failure as classified by the New York Heart Association, or NYHA, classification. Patients who are asymptomatic are classified as NYHA Class 1. Patients with no symptoms can be continued on standard triple therapy with regular follow-up and monitoring.
Patients who are symptomatic despite optimized triple therapy are at higher risk of mortality and poor outcomes, but there are still things that a primary care physician can do to improve the situation. If a patient with NYHA Class 2 or higher is in sinus rhythm and has a heart rate of 70 beats per second, per minute or higher, then Evabradine should be added and you should consider switching the ACE or ARB to an angiotensin receptor neprilysin inhibitor or ARNI, unless there are contraindications. Evabradine and ARNIs are newer types of heart failure medications. Let's take a closer look at each of these.
Evabradine is an add-on therapy indicated in patients with left ventricular ejection fraction or LVEF of 40% or less who are in normal sinus rhythm, whose resting heart rate is 70 beats per minute or higher, and who have been hospitalized for heart failure in the past year. Unlike beta blockers, Evabradine does not affect blood pressure or myocardial contractility. Evabradine is not a replacement for beta blockers.
Instead, it should be added to a standard triple therapy regimen that includes a beta blocker at a maximally tolerated or target dose. Every effort should be made to achieve a target or maximally tolerated beta blocker dose before initiating Evabradine. NYHA Class II or higher patients can also benefit from switching their ACE or ARB to an ARNI. In Canada, the only ARNI currently available is Secubitril Valsartan. The CCS recommends that an ARNI be used in place of an ACE or an ARB in patients with heart failure with reduced ejection fraction who remains symptomatic despite treatment with appropriate doses of guideline-directed medical therapy.
Keep in mind that when switching a patient from an ACE to an ARNI, a washout of 36 hours or longer is needed to reduce the risk of angioedema due to renin-angiotensin system inhibition. In contrast, patients can be directly switched from an ARB to an ARNI without a washout period. The initial dose and rate of titration of Secubitril Valsartan depends on a patient's clinical status and other medications, notably the ACE or ARB the patient is switching from. Note that the side effect profile is not the same as the side effect profile of the patient. and suggested monitoring of patients on an ARNI is similar to that for patients taking an ACE or an ARB.
It should also be noted that the landmark clinical trial excluded patients with elevated serum potassium, renal impairment at a level of 30 mm per minute or lower, and symptomatic hypotension with a systolic blood pressure of less than 100 mmHg. Consult the CCS's e-guidelines website or the product monograph for complete information on monitoring and follow-up of patients on Secubitril-Valsartan. Some important considerations should be taken into account when applying new heart failure therapies in clinical practice. Let's go back to our treatment algorithm for patients with higher-risk NYHA Class 2-4 disease who are more complex. Management of these patients depends on other variables, including sinus rhythm, low heart rate and the presence of atrial fibrillation or a pacemaker.
The next step in this situation is to switch the patient's ACE or ARB to an ARNI unless contraindicated. After other medications have been added as required, symptoms and left ventricular ejection fraction should be reassessed. The optimal frequency of follow-up depends on the patient's clinical status. Let's take a closer look. For asymptomatic and clinically stable NYHA Class I patients, Symptoms and LVEF can generally be reassessed every 1 to 3 years.
More frequent reassessment may be needed, for example, if there is any change in clinical status and or a significant clinical event, such as some heart failure hospitalizations. For NYHA Class 1 to 3 patients whose LVEF remains 35% or lower despite at least 3 months of guideline-directed medical therapy, consider referral for device therapy. These patients should generally have a repeat LVEF assessment every one to five years. Patients with NYHA Class IV should generally be referred to a cardiologist or heart failure clinic since they require more complex management. The frequency of reassessment of patients with NYHA Class IV disease will depend on their clinical status.
Other aspects of heart failure management to be considered for all patients include the identification and management of underlying factors such as ischemia. hypertension and valvular heart disease, and the minimum effective dose of diuretics to maintain uvolemia. Loop diuretics are usually needed since renal function may be volume dependent.
Another important aspect to be considered for all patients is the management of lifestyle factors, including regular exercise, salt intake, daily monitoring of body weight, fluid intake, and immunization status. Teaching self-care encourages the behaviors necessary to maintain or promote health and lifestyle changes and manage the symptoms and effects of living with heart failure. An exercise prescription should be individualized based on the patient's clinical status and situation.
Let's recap. Following an evidence-based therapeutic algorithm for the treatment of heart failure with reduced ejection fraction involves three key steps. First, Initiate standard triple therapy and titrate to maximally tolerated or target therapeutic doses, then reassess symptoms. Second, for patients who remain symptomatic despite triple therapy, who are in sinus rhythm and whose heart rate remains above 70, add evaporating to lower heart rate and switch the patient's ACE or ARB to an ARNI.
Then reassess symptoms and repeat echo to measure the left ventricular ejection fraction. Third, for NYHA Class 1-3 patients whose LVEF remains 35% or lower, refer to a cardiologist or heart failure clinic for consideration for device therapy. NYHA Class 4 patients should be referred to a cardiologist or heart failure clinic for advanced therapies and or palliative care. Regular reassessment of symptoms and left ventricular ejection fraction will depend on the patient's clinical status. Heart failure patients are best managed by a multidisciplinary team that includes a primary care physician and a specialist.
Primary care physicians can usually manage NYHA class 1 and 2 patients. Standard triple therapy has been shown to reduce mortality and improve patient outcomes. Yet, evidence suggests that standard heart failure medications are not initiated in up to 50% of heart failure patients, medications are not optimized in up to 70% of heart failure patients, and that patient adherence is only 40 to 80%. Primary care physicians can improve their heart failure patients' outcomes by doing these three things. 1. Prescribing evidence-based heart failure medications.
Thank you to the many volunteer experts who have contributed countless hours to heart failure guideline development and dissemination.