D. Suryaprabha

Chief Clinical Pharmacist and Assistant Manager – Clinical Research, Kauvery Hospitals, India

*Correspondence: +91 98414 86267;suryaprabha@kauveryhospital.com

Guideline-directed drug treatment for heart failure

Heart failure remains a leading cause of morbidity and mortality globally.

This guest editorial provides recommendations based on contemporary evidence for the treatment of these patients.

The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve the quality of care and align with patients’ interests. Guideline-directed medical therapies at recommended doses are underutilised in patients with Heart failure with reduced ejection fraction (HFrEF).

Many patients with heart failure either do not receive guideline-directed medical therapies or receive doses considerably below the guideline-recommended doses. Despite significant advances in therapies and prevention, their mortality and morbidity are still high and their quality of life poor.

The prevalence, incidence, mortality and morbidity rates reported show geographic variations, depending on the different etiologies and clinical characteristics observed among patients with HF. Medication adherence is very poor and the tolerance of to guideline-based medication is low for Indian patients. There is poor awareness about the condition and its treatment.

Inequitable access to healthcare delivery continues to be a key issue with the Indian healthcare system.

Medication Summary Goal

The goals of pharmacotherapy for heart failure are to reduce morbidity and to prevent complications.

The management of HF patients includes four major pillars of pharmacological treatment. The ideal patient will be managed with ARNi, beta-blockers, MRAs, and an SGLT2 inhibitor.

  1. Angiotensin receptor/neprilysin inhibitor (ARNI) e.g. Sacubitril/valsartan or Angiotensin-converting enzyme inhibitors (ACEIs) or Angiotensin II receptor blockers (ARBs)
  2. Cardio-selective beta-blockers
  3. Aldosterone antagonist e.g. Spironolactone, eplerenone
  4. Sodium-glucose cotransporter-2 (SGLT2) inhibitor

These four drug classes have been studied and have shown benefit benefits for long-term management of HFrEF.

Most of the patient patients receive only one out of four guideline directedguideline-directed drugs!!!

Drugs that can exacerbate heart failure should be avoided, such as nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (CCBs), and most antiarrhythmic drugs (except class III).

The venerable and highly economical economical drug Digoxin, unfortunately , has no more a place in the evidence based evidence-based practice practice of management of heart failure. It may have a limited role in HF associated with Atrial Fibrillation Public healthcare infrastructure for cardiology is inefficient and inadequate to meet the increasing burden of heart failure in India.

There is a compelling need for the initiation of first-line, guideline-directed medical therapy, with HFrEF, particularly for the low-income and middle-income patients

Strategies include the establishment of programmatic approaches to the management of heart failure, targeted education for physicians to strengthen evidence-based practices, and increased patient awareness of the importance of guideline-directed medical therapy at appropriate.

Reference:

Heidenreich, PA et al. AHA/ACC/HFSA guideline for the management of heart failure: A report of the American college of cardiology/American heart association joint committee on clinical practice guidelines. 2022.

D. Suryaprabha

D. Suryaprabha

Senior Executive-Clinical Research

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