Heart failure

ACC president tells all on new heart failure guidelines

New US heart failure management guidelines have backed the use of pro–B-type natriuretic peptide (proBNP) and BNP levels for diagnosing and even preventing heart failure.

Speaking at the CSANZ conference in Perth, Dr Mary Walsh president of the American College of Cardiology and director of the heart failure and cardiac transplantation programs at St. Vincent Heart Centre in Indianapolis, gave delegates a deep dive into the key changes to the guidelines, which were updated this year.

For patients at risk of developing heart failure, Dr Walsh said the guidelines now recommend the use of natriuretic peptide biomarker-based screening to prevent the development of left ventricular dysfunction or new onset HF.

“This is a new recommendation and it could be taken as a population health recommendation that all primary care doctors look at these biomarkers in their patients with hypertension and diabetes for instance.

We certainly don’t want to start a stampede [of referrals to cardiologists] but we do know that proBNP, if elevated, can signal that a patient is at risk.”

Use of the biomarker test, which is not reimbursed or endorsed by Australian guidelines, has also received a class 1A level recommendation (the strongest level) for prognosis and added risk stratification and to aid in the diagnosis of heart failure for patients with unexplained dyspnoea.

“The new guidelines recommend that on admission a proBNP or a BNP level can be very prognostic and a level at the time of discharge can actually help guide our patient’s therapy – we have not had data to support this level of usage of biomarkers in the past,” Dr Walsh told audience members.

Meanwhile updates to recommendations about new drug therapies for HFrEF include a class 1 level recommendation for the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan.

“The guidelines do give a level 1 recommendation for initiation of an ACE inhibitor, an ARB or an ARNI for patients who are symptomatic who have stage C heart failure to reflect new clinical trial data from the PARADIGM HF study,” she said.

According to Dr Walsh, if patients with stable chronic HFrEF have tolerated an ACE inhibitor or an ARB and you want to further reduce morbidity and mortality, that’s where the sacubitril/valsartan combination would come in.

The guideline also gave the strongest recommendation for replacing ACE inhibitors or ARBs with ARNI in patients with chronic symptomatic HFrEF.

But it also warned that an ARNI should not be administered with an ACE inhibitor. Patients should be taken off their ACE inhibitor for 36 hours to make sure that it is out of their system and it should not be administered to anybody who has a history of angioedema.

Hypotension is also a concern associated with the use of ARNI and doctors could think about cutting back the diuretic, Dr Walsh advised.

Meanwhile new recommendations for ivabradine, based on the SHIFT study, support its use in patients who are receiving an evidence-based beta-blocker at a maximum tolerated dose, who are in sinus rhythm and have a heart rate of 70 beats/min at rest.

According to Dr Walsh, the drug has been shown to be beneficial in reducing hospitalisation in symptomatic patients with stable chronic HFrEF with an ejection fraction less than 35%.

“My patients on ivabradine are generally younger patients who have persistent tachycardia in spite of high dose beta blockers and whether or not we see additional use of ivabradine down the road will have to await other trials,” she told the conference.

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