SGLT2 inhibitors and angiotensin receptor neprilysin inhibitors (ARNis) are the ‘new kids on the block’ in the latest update of national heart failure guidelines presented at CSANZ 2018.
The National Heart Foundation of Australia and CSANZ Guidelines for the Prevention, Detection and Management of Heart Failure in Australia 2018 are a significant revision of the 2011 version and were well received at the meeting including by international guests.
Chair of the guidelines working group Associate Professor John Atherton said the role of ACE inhibitors was still central in the pharmacological prevention of heart failure.
“But what is new is we have acknowledged this new class of drug, the sodium-glucose cotransporter 2 (SGLT2) inhibitors, which we have recommended in patients with type 2 diabetes associated with cardiovascular disease with insufficient glycaemic control despite metformin, to reduce the risk of cardiovascular events and also decrease the risk of heart failure hospitalisation.”
The strong recommendation was based on high quality of evidence from the EMPA-REG and CANVAS studies of empagliflozin and canagliflozin, said Professor Atherton, Director of Cardiology, Royal Brisbane and Women’s Hospital.
Pharmacological management of chronic heart failure in 2018 remains similar to the 2011 guidelines – driven by ACE inhibitors, the ‘heart failure’ beta-blockers such as bisoprolol, carvedilol and metaprolol, and mineralocorticoid receptor antagonists (MRA).
“But the new kids on the block here are the ARNis, referring of course to sacubitril-valsartan being recommended as a replacement for an ACE inhibitor with at least a 36-hour washout period because of the risk of angioedema,” he said.
Recommendations around the use of angiotensin receptor blockers (ARBs) and ivabradine in patients with persistent HFrEF are unchanged since 2011.
The 2018 guidelines also include specific recommendations for patients with a mildly impaired ejection fraction (LVEF 41-49%) although it included that sub-group of patients within the HFrEF category rather than follow European guidelines, which created a mid-range EF category between HFrEF and HFpEF.
“We also thought it was important to include a recommendation that unless you identify and correct a reversible cause of heart failure – maybe tachycardia has been addressed or mediated or perhaps alcohol has been withdrawn – neurohormonal antagonists should be continued at target doses in patients with heart failure associated with a recovered or restored ejection fraction, to decrease the risk of occurrence.”
Associate Professor Atherton said while there wasn’t enough evidence to make recommendations in HFpEF, they did provide some practice advice such as treating congestion with diuretics and managing risk factors such as hypertension.
“And we thought there was enough evidence to make a comment that low-dose spironolactone might be considered to reduce heart failure hospitalisations.”
Interventions clarified
Associate Professor Atherton said recommendations regarding devices, procedures and surgery were largely unchanged from 2011 guidelines although some were now a little clearer.
For example, recommendations for cardiac resynchronisation therapy (CRT) in patients with HFrEF were separated out based on QRS duration.
“We have made a specific recommendation against CRT in patients with QRS <130 ms because of lack of efficacy and concern of harm in this group.”
“We’ve also acknowledged that CRT should be considered in patients with EF <50% accompanied by high-grade atrioventricular block requiring pacing.”
“What we hadn’t done in 2011 was make a comment about atrial fibrillation however we thought it was important to do so. Very similarly to those with sinus rhythm, it’s important to ensure there is sufficient biventricular capture if you undertake this approach.”
He said implantable pulmonary artery pressure monitoring may be considered in patients with reduced or preserved LVEF and persistent symptoms despite optimal care.
“However we thought it was important to make a comment that this is provided there are systems in place to ensure daily upload and at least weekly review of those pressure monitoring data. Because it’s not data monitoring reducing hospitalisations here, it’s what you do with the information.”
Percutaneous mitral valve procedures for repair and replacement are also new in the guidelines however as weak recommendations based on low quality of evidence.
In contrast, transcutaneous aortic value implantation (TAVI) for patients with severe aortic stenosis and heart failure at intermediate to high operative mortality risk, and deemed suitable for TAVI following assessment by a heart team, has been given a strong recommendation based on high quality RCTs.
The guidelines also made a strong recommendation to consider catheter ablation in patients with LVEF ≤35% who present with recurrent atrial fibrillation to decrease mortality and hospitalisation.
Multidisciplinary models of care get the nod
Associate Professor Atherton said the guidelines acknowledged Australia’s geographical context by recommending multidisciplinary telemonitoring or telephone support programs for patients where access to face-to-face programs was limited.
“We also thought the evidence was sufficiently strong to include a recommendation regarding nurse-led medication titration and this has been particularly in beta-blockers but we also have evidence in a Cochrane Review that this approach in patients who have not achieved target with neurohormonal antagonists can improve clinical outcomes including hospitalisations.”
The guidelines also made a strong recommendation for the involvement of palliative care early in the trajectory towards end-stage heart failure to alleviate symptoms, improve quality of life and decrease hospitalisation.
Perspectives and praise
Professor Anthony Coats, president-elect of the Heart Failure Association of the ESC, said the Australian guidelines were a ‘fantastic piece of work and the most up to date analysis of the evidence we have’.
Subtle differences between ESC and Australian guidelines perhaps reflected the fact that the European document was written only by cardiologists whereas the Australian working group was multidisciplinary.
He said the ESC also used their own experts to perform the literature reviews whereas Australia had outsourced pre-specified searches.
“There is an argument for having that objectivity.”
He added he did not see Europe moving away from their mid-range ejection fraction category.
Professor Javed Butler, from the University of Mississippi in the US, praised the Australian guidelines for being written for practising clinicians rather than ‘guideline junkies’.
He particularly complimented the Australian guidelines for including recommendations on recovered ejection fraction, and the clarity of language and algorithms.
Differences between US and Australian guidelines were largely temporal and otherwise due to the respective balance of rationalists versus empiricists on guideline working groups, he said.