GDMT for heart failure and the clinician's conundrum

Abstract

Therapeutic advances in management of CHF have decreased mortality and have impacted progression in patients with mild to moderate heart failure. Aggressive campaigns by cardiology societies aimed at increasing implementation of these measures in routine practices have almost generalized the treatment of heart failure irrespective of individual variations of clinical status of patients and stages of heart failure. This explains why morbidity compression and quality of life improvement have not been realized fully particularly in patients with advanced disease. To examine whether GDMT for CHF is backed by unambiguous evidence of clinical efficacy for its global implementation in every patient at all stages of the syndrome. ACC/AHA, ESC Guidelines for CHF, and their updates were reviewed. Clinical trial cited in the guideline documents and other pertaining published literatures were analyzed.FindingsMany of the recommended GDMT for CHF lack unequivocal evidence of clinical efficacy in patients with diverge etiology of heart failure and concomitant comorbid conditions Some of the recommendations which are useful in early stages, lack evidence of efficacy in more advanced stages of heart failure. Application of results of research trials in patients beyond their inclusion and exclusion criteria, appears mere extrapolation, Clinicians are faced with the conundrum of implementing the recommendations without indubitable evidence of their efficacy in every patient of their practice.ConclusionA reappraisal of Guidelines is needed to address outstanding questions pertaining to the efficacy of recommendations and plug the knowledge gaps without assumption and extrapolation of results of RCTs beyond their inclusion and exclusion criteria.

Contemporary economic burden in a real‐world heart failure population with Commercial and Medicare supplemental plans

“…In the present study, the proportion of patients on triple therapy (three evidence‐based HF therapies) remained less than 20% and use of ARNI and SGLT2i remained less than 2%. Various patient‐level (affordability, willingness to take multidrug regimens), clinician‐level (comfort with newer agents, knowledge gaps, treatment inertia), and health system‐level (local treatment availability, access to healthcare) issues may contribute to observed gaps in evidence‐based therapies 19,21,22,24 . Multilevel quality improvement initiatives are needed to promote equitable and widespread care practices to optimize GDMT.…”

ARNI or ARB Treats Residual Left Ventricular Remodelling after Surgery for Valvular Regurgitation: ReReRe study protocol

“…This group of patients has been frequently underrepresented in previous HF trials, which might have discouraged clinicians from generalizing GDMT for HF. 8 Despite the common practice of implementing neurohumoral blockade therapy for HFrEF, there is a lack of definite recommendations in guidelines with supporting evidence. The post hoc analysis of the PARADIGM‐HF study confirmed consistent additional benefits of ARNI over enalapril across different aetiologies of HF, including ischaemic (60.0%), hypertensive (9.5%), idiopathic HF (11.5%), and others (19.0%).…”

“…Despite the lack of solid clinical evidence in this group of patients, 4 , 8 angiotensin‐converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) are recommended if patients present with heart failure with reduced ejection fraction (HFrEF) before or after valve interventions. 4 , 9 In recent years, the superiority of the angiotensin receptor‐neprilysin inhibitor (ARNI) sacubitril/valsartan over ACEI or ARB in HFrEF has been recognized, 4 , 10 , 11 but it is uncertain whether this also applies to residual LV remodelling after AR or MR surgery.…”

Out with the Old and In with the New: Primary Care Management of Heart Failure with Preserved Ejection Fraction

“…As an alternative, the much-supported option of guideline-directed medical therapy for HF should, in theory, be easier to apply in primary care given the availability of subsidised and approved therapies. [ 17 ] However, as typically occurs in the primary care HF population, this strategy is not so easily applied when a GP is faced with an ‘atypical’ patient who would have been excluded from a clinical trial because of their advanced age, type of HF (e.g. predominantly right sided) and multimorbidity.…”

“…Thus, as with any new agent or clinical indication in HF, there is an inherent expectation on primary care to consider and manage complicated issues around the benefits versus risks of continuing agents, such as the SGLT2 inhibitors, while attempting to interpret trial evidence derived from typically younger, less complicated patients. [ 17 ]…”