Heart Failure Management in 2023: Challenges and Opportunities

The clinical characteristics of the HF phenotypes are shown in Table 1. Dr Devlin noted that HFpEF results in significant morbidity in New Zealand communities and accounts for approximately 40% of acute HF hospital admissions.22

Table 1: Clinical characteristics of HF phenotypes. Adapted from Savarese et al (2022).23

Phenotype

Age

Women

Ischemic heart disease

Atrial fibrillation

Hypertension

Chronic kidney disease

Natriuretic peptide levels

HFpEF and HFmrEF management has changed

Prior to 2021, patients with HFpEF were investigated for significant coronary artery disease, treated to a target BP ≤120/80 mmHg (particularly if LVH is present), prescribed a diuretic for symptoms and the possibility of AF considered. Practice recommendations for patients with HFpEF and HFmrEF have recently changed, however, due to studies involving dapagliflozin (DAPA-HF) and empagliflozin (EMPEROR-Preserved).24,25 These studies showed a significant and comparable reduction in HF hospitalisations with SGLT2 inhibitors, which were well tolerated in patients with HFpEF and HFmrEF. Guidelines are likely to be updated worldwide following these studies.

Questions and answers

Dr Devlin provided the following answers to questions from the audience:

2023 management of patients with HFpEF and HFmrEF should include:

• Initiating an SGLT2 inhibitor.

• An ACE inhibitor/ARB for BP.

• Consider spironolactone.

• Consider switching to ARNI.

• Exclude ischaemia.

• Consider the possibility of AF.

CASE STUDY 2: 71-year-old female with HFpEF

Dr Devlin returned to case study two. The patient began treatment with:

• Empagliflozin 10 mg daily as she had T2D.

• Spironolactone 12.5 mg daily.

The possibility of ischaemic heart disease was investigated and excluded.

Dr Devlin finished his presentation with three key questions for all clinicians to ask on Monday:

• Are my patients with HF on optimal evidence-based care?

• Does this include an aldosterone antagonist and consideration of sacubitril/ valsartan?

• If the patient has T2D, are they eligible for an SGLT2 inhibitor?

1. In the experience of one attendee, many patients who have been discharged from hospital following an admission for acute HF are experiencing symptoms of postural hypotension. Is it possible that patients with NYHA II symptoms tolerate the combination of four recommended HF medicines better than patients with more advance HF, i.e. type IV? Symptomatic postural hypotension is an important limitation to optimisation of evidence-based care, particularly for patients with more advanced HF. When present, the need for other medications that lower blood pressure should be reviewed. For example, if a patient is taking 80 mg of frusemide and it is not possible to up-titrate sacubitrilvalsartan due to symptomatic postural hypotension, is it possible to consider reducing the dose of frusemide? Are there other medicines that can be reduced to reduce the symptoms of hypotension?

2. What is the next step if a patient becomes hyperkalemic on the foundational medicines?

Firstly, Dr Devlin would consider if there were other explanations for an elevated potassium level. Withholding spironolactone would be one possible strategy in this situation as well as being cautious when restarting it, e.g. spironolactone 12.5 mg every second day. If the patient’s renal function has declined significantly, it may be appropriate to also withhold the ACE inhibitor/ARB. Treatment needs to be individualised in this situation.

3. What is the role of NT-pro BNP for monitoring worsening HF?

In Dr Devlin’s opinion, NT-pro BNP is a useful test to firstly exclude HF. In his practice, he also finds NT-pro BNP helpful in optimising evidence-base care. Finally, if a patient with HF has had a stable NT-pro BNP but their level is now elevated, this should be cause for concern and potential reasons for the elevation investigated.

4. When is the best time to deprescribe frusemide given that long-term treatment is not recommended, but HF patients are often taking this medicine for years?

The ongoing need for medication needs to be constantly reviewed. In the case of frusemide, it does not make sense for an asymptomatic patient to continue treatment as there is no known prognostic benefit for HF patients to be taking frusemide, it is purely to treat symptoms. Also, as discussed previously, continuing diuretics in a patient with minimal symptoms may limit the ability to maximise treatments that improve outcomes.

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This article was commissioned by Boehringer Ingelheim (NZ) Ltd and Eli Lilly (NZ ) Ltd. The content is entirely independent and based on studies and the author’s opinion. The views expressed do not necessarily reflect the views of Boehringer Ingelheim and Eli Lilly. Before prescribing any prescription medications mentioned in this article please consult the full data sheet. Treatment decisions based on these data are the full responsibility of the prescribing healthcare professional.