AHA/ACC/HFSA Guidelines: New Ways to Address Treatment and Equity in HF Care

A panel of 5 expert cardiologists discussed the ways that the recently published 2022 AHA/ACC/HFSA Guidelines for the diagnosis and treatment of heart failure (HF) can be used regularly, specifically in management of heart failure and ways to make sure treatment using the guidelines is equitable.

Management and Treatment of Heart Failure: An Achievable Goal

The management and treatment of heart failure was the focus of the majority of the panel, as 3 cardiologists presented ways in which HF with reduced ejection fraction (HFrEF), HF with mid-range left ventricular ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF) can be treated using new data and the new guidelines.

According to Biykem Bozkurt, MD, who gave the first presentation of the panel, the first step to treating patients with HFrEF is to initiate quadruple therapy. Time is of the essence, she said, which makes this first step the most important.

“The new modalities of treatment is associated with significant improvement in cardiovascular death and heart failure hospitalization as early as 30 days,” said Bozkurt. Medications for the first step can be started simultaneously at low doses or can be started sequentially without a need to achieve the target dosing before starting the next medication, which is more helpful in places where simultaneously starting 4 medication doses is not feasible.

The second step of treating HFrEF is to titrate to the target doses and to reassess.

“This is important because we do have evidence for better outcomes with the optimization of doses with beta-blockers or ACE [angiotensin-converting enzyme] inhibitors,” said Bozkurt.

The third and fourth steps are to consider additional therapies, including ivabradine, vericiguat, digoxin, and potassium binders. Bozkurt said that the models of care are evolving after the pandemic as telehealth has become more prevalent. The key, she said, is to not withhold medications or therapies from patients for perceived stability. She also believes that patients may need to be included in self-titration in the future.

Lynne Warner Stevenson, MD, FHFSA, spoke about treatment of HFmrEF. She emphasized that it’s usually a transition state and makes up 22% of all patients with HF. Guideline recognition of HF with improved ejection fraction (EF) and HFmrEF was first included in 2013 and is included in the guidelines published in 2022.

Stevenson said that treatment of HFmrEF should represent the differences in the etiology and routes to the disease. This includes keeping patients on the medications that improved their EF to start. Diuretics could be reduced if their EF has improved. If normal EF is falling, low EF therapies could be added. Caution should be taken when treating patients with structural heart disease and restrictive heart disease.

Stefan Anker, MD, PhD, presented new data on treatment options for patients with HFpEF. Anker focused on sodium-glucose cotransporter-2 (SGLT2) inhibitors, which have had promising results in patients with HFpEF and HFmrEF. He presented data that would be released later in the week on patients with HFpEF and how effectively they were treated with SGLT2 inhibitors.

The new data found that patients with HFpEF who used a SGLT2 inhibitor had 17% reduced risk of cardiovascular death or HF hospitalization and 22% reduced risk of a first HF hospitalization. This new data could prompt SGLT2 inhibitors to be included in the next guidelines to treat HFpEF, said Anker.

Equity in Care: How to Ensure Adequate Treatment for All

With new treatments and guidelines, the importance of ensuring all patients get proper care and treatment for HF is important.

Clyde Yancy, MD, spoke about how to advance equity in HF prevention. Yancy said that the guidelines provide “summative statements on important information in heart failure.”

He said that there has been an increase in HF-related deaths and hospitalizations in the United States. Black men have had an increase in the risk of death due to HF, especially in men aged 64 years and younger. This necessitates change in the way that HF treatment is addressed.

“I am particularly enthused that in this version of the guidelines, different from any other version we’ve produced, we have a robust section addressing the primary prevention of heart failure,” said Yancy. “There are 4 evidence-based, class 1 indicated interventions to prevent heart failure and 2 that are class 2A.”

These interventions include optimal control of blood pressure, optimal management of cardiovascular disease, and genetic screening and counselling for those with a genetic history.

Yancy also said that the guidelines now make a specific statement in targeting vulnerable populations. Some treatments have been proven effective regardless of race or ethnicity, such as the angiotensin recepter/neprilysin inhibitor and SGLT2.

Yancy also said that thinking about the community-based factors that contribute to HF, such as housing, employment, and access to health care.

“If we’re going to fundamentally change the prevention paradigm from just treating hypertension and diabetes, targeting obesity and diet, we must understand the necessity to embed equity in all clinical decision making, to emphasize lifestyle changes especially in those most at risk, to consider the adverse impact of social determinants of health, and work at a population health level to reduce the burden of atherosclerotic cardiovascular disease,” said Yancy.

Prateeti Khazani, MD, MPH, also spoke on how referring patients with HF to HF specialty care is now a class 1 recommendation in the new guidelines. The “golden window” of referral, she said, was when a patient was displaying New York Heart Association III-IV symptoms, frequent hospitalizations, recurrent arrhythmias or implantable cardioverter-defilbrillator shocks, downtitration of or inability to tolerate guideline-directed medical therapy, and worsening renal function.

Khazani said that referral takes a lot of shared decision-making between the doctor and patient. She also said that focus should be directed upstream, as Black individuals and women are often missed in referrals and therefore don’t get the heart replacement therapies needed. Women make up only 25% to 35% of all people evaluated for heart replacement therapies whereas Black individuals make up only 22% to 28% of all evaluated patients compared with 70% to 74% White individuals.

“There are multiple factors that lead to unwarranted variations in advanced heart failure care. One of the main ones that has not been studied is referral and it’s something in the future that I hope a lot of us will try to do,” concluded Khazani.