Guideline updated to include new drugs for stage C heart failure with reduced ejection fraction

A 2013 guideline was updated last week, adding 2 new medications as treatment options for stage C heart failure patients with reduced ejection fraction.

The update to the 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guideline for the Management of Heart Failure adds the angiotensin receptor-neprilysin inhibitor (ARNI) valsartan/sacubitril, and the sinoatrial node modulator ivabradine to the list of treatment options for stage C heart failure with reduced ejection fraction.

According to the new recommendations, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or an ARNI, along with a beta-blocker and an aldosterone antagonist, is the new recommended therapy to reduce morbidity and mortality in patients with chronic symptomatic heart failure with reduced ejection fraction. An ARNI should replace ACE inhibitors or ARBs in stable patients with mild to moderate heart failure on these therapies who have adequate blood pressure and are otherwise tolerating standard therapies well. ARNIs, however, should not be used with an ACE inhibitor and should not be used by patients with a history of angioedema.

Other specific recommendations are as follows:

• Although the use of an ARNI in lieu of an ACE inhibitor for heart failure with reduced ejection fraction has been found to be superior, for those patients for whom ARNI is not appropriate, continuing an ACE inhibitor for all classes of heart failure with reduced ejection fraction remains strongly advised.
• The use of ARBs to reduce morbidity and mortality is recommended in patients with prior or current symptoms of chronic heart failure with reduced ejection fraction who are intolerant of ACE inhibitors because of cough or angioedema. Head-to-head comparisons of an ARB versus ARNI for heart failure do not exist. For those patients for whom an ACE inhibitor or ARNI is inappropriate, use of an ARB remains advised.
• An ARNI should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor and should not be administered to patients with a history of angioedema.
• Ivabradine can be beneficial to reduce heart failure hospitalizations in patients with symptomatic (New York Heart Association class II-III) stable chronic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) who are receiving guideline-directed evaluation and management, including a beta-blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 beats per minute or greater at rest.

The update appeared online May 20 in the Journal of the American College of Cardiology, Circulation, and the Journal of Cardiac Failure.