Patients hospitalized with HF
The 2021 guidelines had recommended that patients hospitalized with acute HF be started on evidence-based meds before discharge and that they return for evaluation 1 to 2 weeks after discharge. But the recommendation was unsupported by randomized trials.
That changed with the 2022 publication of STRONG-HF, in which a strategy of early and rapid uptitration of guideline-directed meds, initiated predischarge regardless of LVEF, led to a one-third reduced 6-month risk for death or HF readmission.
Based primarily on STRONG-HF, the focused update recommends “an intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge and during frequent and careful follow-up visits in the first 6 weeks after hospitalization” to reduce readmission and mortality: Class I, level of evidence B.
“There was a large consensus around this recommendation,” said STRONG-HF principal investigator Alexandre Mebazaa, MD, PhD, a co-author of both the 2021 and 2023 documents. Conducted before the advent of the four pillars of drug therapy, sometimes called quartet therapy, the trial’s requirement for evidence-based meds didn’t include SGLT2 inhibitors.
The new focused update considers the new status of those agents, especially with regard to their benefits independent of LVEF. So, it completed the quartet by adding empagliflozin or dapagliflozin to the agents that should be initiated predischarge, observed Dr. Mebazaa, University Hospitals Saint Louis‐Lariboisière, Paris, at the focused-update’s ESC 2023 sessions.
The new document also follows STRONG-HF with its emphasis on “frequent and careful follow-up” by recommending certain clinical and laboratory evaluations known to be prognostic in HF. They include congestion status, blood pressure, heart rate, natriuretic peptide (NT-proBNP) and potassium levels and estimated glomerular filtration rate.
Dr. Mebazaa stressed the importance of monitoring NT-proBNP after discharge. “What we saw in STRONG-HF is that sometimes the clinical signs do not necessarily tell you that the patient is still congested.”
After discharge, he said, NT-proBNP levels “should only go down.” So, knowing whether NT-proBNP levels “are stable or increasing” during the med optimization process can help guide diuretic dosing.
HF with comorbidities
The new document includes two new Class I recommendations for patients with HF and both type 2 diabetes and chronic kidney disease based on several recent randomized trials and meta-analyses.
The focused update recommends SGLT2 inhibitors as well as the selective, non-steroidal MRA finerenone (Kerendia) in HF patients with CKD and type-2 diabetes. Both Class I recommendations are supported by a level of evidence A.
The SGLT2 indication is based on DAPA-CKD and EMPA-KIDNEY plus meta-analyses that included those trials along with others. The recommendation for finerenone derives from the FIDELIO-DKD and FIGARO-DKD trials and a pooled analysis of the two studies.
The 2023 focused update also accounts for new clinical-trial insights for patients with HF and iron deficiency. The 2021 document featured recommendations for the diagnosis and iron-repletion therapy in such cases, but only as Class IIa or at lower low levels of evidence. The focused update considers more recent studies, especially IRONMAN and some meta-analyses.
The 2023 document indicates intravenous iron supplementation for symptomatic patients with iron deficiency and either HFrEF or HFmrEF to improve symptoms and quality of life (Class I, level of evidence A), and says it should be considered (Class IIa, level of evidence A) to reduce risk for HF hospitalization.
When the task force assembled to plan the 2023 focused update, Dr. Gardner observed, “the first thing we thought about was the nomenclature around the phenotyping of heart failure.”
Although the 2021 guidelines relied fundamentally on the distinctions between HFrEF, HFmrEF, and HFpEF, it had become apparent to some in the field that some meds, especially the SGLT2 inhibitors, were obscuring their LVEF-based boundaries, at least with respect to drug therapy.
The 2023 document’s developers, Dr. Gardner said, seriously considered changing the three categories to two, that is HFrEF and – to account for all other heart failure – HF with normal ejection fraction (HFnEF).
That didn’t happen, although the proposal was popular within the task force. Any changes to the 2021 document would require a 75% consensus on the matter, Dr. Gardner explained. When the task force took a vote on whether to change the nomenclature, he said, 71% favored the proposal.
Disclosures for members of the task force can be found in a supplement to the published 2023 Focused Update.
A version of this article first appeared on Medscape.com.