2
Overview
Top 10 Take-Home Messages:
1. Guideline-directed medical therapy (GDMT) for heart failure (HF)
with reduced ejection fraction (HFrEF) now includes 4 medication
classes which include sodium-glucose cotransporter-2 inhibitors
(SGLT2i).
2. SGLT2 inhibitors have a 2a recommendation in heart failure with
mildly reduced ejection fraction (HFmrEF). Weaker recommendations
(2b) are made for ARNi, ACEi, ARB, MRA and beta blockers in this
population.
3. New recommendations for HFpEF are made for SGLT2 inhibitors
(2a), MRAs (2b) and ARNi (2b). Several prior recommendations have
been renewed including treatment of hypertension (1), treatment of
atrial fibrillation (2a), use of ARBs (2b) avoidance of routine use of
nitrates or phosphodiesterase-5 inhibitors (3-no benefit).
4. Improved LVEF is used to refer to those patients with a previous
HFrEF who now have an LVEF >40%. These patients should continue
their HFrEF treatment.
5. Value statements were created for select recommendations where
high-quality cost-effectiveness studies of the intervention have been
published.
6. Amyloid heart disease has new recommendations for treatment
including screening for serum and urine monoclonal light chains,
bone scintigraphy, genetic sequencing, tetramer stabilizer therapy,
and anticoagulation.
7. Evidence supporting increased filling pressures is important for
the diagnosis of HF if the LVEF is >40%. Evidence for increased
filling pressures can be obtained from non-invasive (e.g., natriuretic
peptide, diastolic function on imaging) or invasive testing (e.g.,
hemodynamic measurement).
8. Patients with advanced HF who wish to prolong survival should
be referred to a team specializing in HF. A heart failure specialty
team reviews HF management, assesses suitability for advanced
HF therapies and uses palliative care including palliative inotropes
where consistent with the patient's goals of care.
9. Primary prevention is important for those at risk for HF (Stage A) or
pre-HF (Stage B). Stages of HF were revised to emphasize the new
terminologies of "at risk" for HF for Stage A and Pre-HF for Stage B.
10. Recommendations are provided for select patients with HF and iron
deficiency, anemia, hypertension, sleep disorders, diabetes type 2,
atrial fibrillation, coronary artery disease and malignancy.
