ACC Updates Heart Failure Guidance, Highlights New Drugs

Streamlined interim heart failure guidance, including newer therapies and acknowledging the changes in care wrought by the COVID-19 pandemic, was released by the American College of Cardiology (ACC).

Angiotensin receptor-neprilysin inhibitors (ARNIs) and SGLT2 inhibitors were added to the treatment algorithms for new-onset and chronic heart failure in this update to the ACC's 2017 expert consensus decision pathway (ECDP) for treatment of heart failure with reduced ejection fraction (HFrEF).

The document was meant to serve as interim guidance while the ACC drafts more comprehensive heart failure guidelines, according to the writing group chaired by Thomas Maddox, MD, MSc, of Washington University School of Medicine in St. Louis.

"Since the publication of the 2017 ECDP, numerous clinical trials have been reported, providing updated knowledge to inform the clinical management of patients with HFrEF. In addition, more knowledge is now available regarding biomarkers and imaging, management of comorbidities, and the mitigation of difficulties encountered in care coordination," the authors wrote online in the Journal of the American College of Cardiology.

Notably, the new ECDP touches on the "somewhat controversial" topic of percutaneous therapy for functional mitral regurgitation, given conflicting results from COAPT and MITRA-FR. Maddox and colleagues urged only that guideline-directed medical therapy (GDMT) be optimized before referral for the procedure.

Other recommendations made included how to better coordinate care, improve medication adherence, contain costs, and integrate palliative care and the transition into hospice care.

Finally, the ECDP writers acknowledged that COVID-19 will likely have a lasting impact on how clinicians use multiple drugs for HFrEF to achieve optimal therapy for a given patient.

"During the COVID-19 pandemic, virtual care to allow for outpatient GDMT titration has been useful in certain patients and will likely take on a larger role in HFrEF care post-pandemic," according to the ACC group.

Whether GDMT titration delivered virtually is comparable to that from in-person visits is unclear, however.

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